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HomeMy WebLinkAbout0067 AUTUMN DRIVE - Health 67 AUTUMN DR., CENTERVILLE A = 168 089 Si•%� _-p® �JICYCayi UPC 12534 No.2153LOR HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ; 67 Autum Dr ' Property Address h Victoria Realty Group Owner Owner's Name information is -'�'�, required for every Centerville ✓ , Ma. 02632 10/25/2017 page. Citylrown 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 A. General Information / (-a �t a---,filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections reD Company Name 624 Old Barnstable Road Company Address I Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 10/28/2017 _ 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 .CoyVs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 page. Citylrown 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: This 2 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding two leaching pits. At the time of the inspection both leaching pits had less than one foot of ponding water. 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): i t5ins.doc-rev.6116 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 67 Autum Dr Property Address Victoria Realty Group Owner Owners Name information is required for every Centerville Ma. 02632 10/25/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 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 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 page. Cityrrown 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 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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- 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 7 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): `220 GPD t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •' 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: In 2016 66,000 gallons were used and in 2015 50,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: 082017 Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 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 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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.doc-rev.6/16 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 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is Centerville Ma. 02632 10/25/2017 required for every 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"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: Standard H-10 1000 gallon septic tank Sludge depth: 4" t5ins.doc-rev.6116 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 M 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 page. Cityrrown 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 36" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): At the time of the inspection both leaching pits had less than one foot of ponding water. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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.): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 . Commonwealth eaIt of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4'M 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is required for every Centerville Ma. 02632 10/25/2017 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 �X1 3 Z = 35 3 116 � 9 y �} jr C - y 2 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Autum Dr Property Address Victoria Realty Group Owner Owner's Name information is Centerville Ma. 02632 10/25/2017 required for every page. Cityrrown 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: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Autum Dr M Property Address Victoria Realty Group Owner Owner's Name information is Centerville Ma. 02632 10/25/2017 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 0&6 Commonwealth of Massachusetts tW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 67 Autumn dr Property Address w Juan Marichal Owner Owner's Name ' information is nterville Ma 02632 6/5/17 required for every Ce rid page. City/Town State Zip Code Date of Inspectig6 01 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information // filling out forms <54 1,23 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ,Q Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 6/5/17 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa 1 of 17 VIE ti Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown 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: y® 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: System contains a 1,000 Gallon septic tank as well as a concrete distribution box and a 1,000 gallon leach pit. Leach pit had 1ft of liquid in it at time of inspection. Stain line indicates level has been within 26"on invert pipe 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): l5ins-3/13 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 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is Centerville Ma 02632 6/5/17 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form v a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown 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 ❑ Y P supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 279 Gpd 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/user Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1,000 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original to home Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line Septic Tank(locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 ' If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape 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.): Baffles are in place 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•3113 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 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityfrown 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 Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts •W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is Centerville Ma 02632 6/5/17 required for every 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.): Pit is functioning as designed 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•3/13 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 wM 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 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 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityfrown 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 G \ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 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: 12+ ft 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: Usgs maps have ground water app 14' below septic system Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Autumn dr Property Address Juan Marichal Owner Owner's Name information is required for every Centerville Ma 02632 6/5/17 page. Cityfrown 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•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I ;v ` \ Conunonwealth of Massachusetts 2 s 199s Executive Office of Envirommental Affairs Dept. of Environmental Protection ,Jolui Grad One winter Street,Boston,Ma. 02108 � - _D.E.P. Title V Septic Inspector JAA1 2 0 1999 P.O. Box 2119 Teaticket, MA 02536 (508) 564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 67 AUTUMN DR.CENTERVILLE MAP 168 PAR 89 L 3A Address of Owner: Date of Inspection: 1118199 (If different) Name of Inspector: JOHN GRACI ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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-site sewage disposal systems. The system: This Inspection Is based on criteria donned In Title V X Passes code 310CMR16.303.Nry findings are ofhow the system is _ Conditionally Passes performing at the time of the inspection.My inspection does — Needs F rt r Evaluation By the Local Approving Authority septic system and any ofIts any warranty or uarantee ofthe longevity components useful life.orthe Fails Inspector's Signature: Date: 1118199 The System Inspector shal submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 8] SYSTEM CONDITIONALLY PASSES: _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no, or not determined(Y, N, or ND). 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 CoThpliance(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 conforming septic tank as approved by the Board of Health. (revised 04r27197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 AUTUMN DR.CENTERVILLE MAP 168 PAR 89 L 3A Owner: ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:V18199 _ Sewage backup or.breakout or high.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined 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 in 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 cesspool. SAS is in hydraulic failure. (revlsed 04127W) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 87 AUTUMN DR.CENTERVILLE MAP 168 PAR 89 L 3A Owner: ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:1118199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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 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. 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] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: _ 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 007)97) I I F I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 67 AUTUMN DR.CENTERVILLE MAP 169 PAR 89 L 3A Owner: ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:1119199 Check if the following have been done:YoU must indicate either"Yes"or"No"as to each of the following: ,c_ _ Pumping information was requested of the owner,occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x — As built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System,have been located on the site. x 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. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, it different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)) (revised 04127197) i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 AUTUMN DR.CENTERVILLE MAP 159 PAR 99 L 3A Owner: ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:1119199 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 330 g P Number of bedrooms: 3 Number of current residents: U Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage g (gpd): nra Sump Pump(yes or no): No Last date of occupancy: OCTOBER311998 COMMERCIAL/INDUSTRIAL: Type of establishment: nra Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) nra Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: nra System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: Na TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source information: NEW SYSTEM WAS INSTALLED IN 1993 PERMIT#93-646 Sewage odors detected when arriving at the site: (yes or no) No (reylaed 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 AUTUMN DR.CENTERVILLE MAP 169 PAR 89 L 3A Owner: ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:'111E199 SEPTIC TANK: x (locate on site plan) Depth below grade: 6" Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) If tank is metal, list age r,Ia . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L6'6"H5•7"W4'10" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness:"' Distance from top of scum to top of outlet tee or baffle:e" Distance form bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined: MEASURED Comments: (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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS. GREASE TRAP:_ (locate on site plan) Depth below grade: nIa Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle:Na Date of last pumping;d, Comments: (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.) rda BUILDING SEWER: (Locate on site plan) Depth below grade: 12" Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction llne:rOWN Diameter: nla Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 AUTUMN DR.CENTERVILLE MAP 169 PAR 89 L 3A Owner: ROBERT HIGHLAND;34 CU8HMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:1118199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nra Capacity: nra gallons Design flow: rva gallons/day n working order?—Yes No Alarm level:_nia — Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nra DISTRIBUTION BOX: x (locate on site plan) Depth of liquid level above outlet invert: LIQUID LEVEL YATH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nfa (revised04r1719T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 AUTUMN DR.CENTERVILLE MAP 168 PAR 89 L 3A Owner: ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 Date of Inspection:1118199 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits, number: 2.1000 GALLON LEACH PITS leaching chambers,number:r9a leaching galleries,number: Wa leaching trenches,number,length: rda leaching fields,number,dimensions:rda overflow cesspool,number:nla Alternate system: rda Name of Technology:__,Na Comments. (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. CESSPOOLS: (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: nla Depth of solids layer: rda Depth of scum layer:. rda Dimensions of cesspool: rda Materials of construction: rda Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda PRIVY:_ (locate on site plan) Materials of construction: rda Dimensions: nla Depth of solids: Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) ma (reyleed 04r17197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 67 AUTUMN DR.CENTERVILLE MAP 168 PAR 89 L 3A ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 1118199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) Deck- 6 Inc �g 6A P gg a� Page 9 of 10 (revised 04r27197) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 67 AUTUMN DR.CENTERVILLE MAP 168 PAR 89 L 3A ROBERT HIGHLAND;34 CUSHMAN RD.WHITE PLAIN N.Y.10606 1118190 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revisedW27197) page 10 of 10 I TO BARNSTABLE C--�'LOCATIOdj-lkk\,� SEWS(AGE # VILLAGE !kf �'I(U� ASSESSOR'S MAP & for INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: pe) (size) NO.OF BEDROOMS BUILDER OR OWNER � Svlk" Ali PERMUDATE: 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 we ezict within 300 feet of leaching facility) Feet Furnished by .. �c�- 6 ��� Eck © � a �C . � � ��� �`� � P � �� � � �� � �� � ��� No..... �1..1. � Fas..... ....30 . 00 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Ali t t WDiriplimal Wortw Ta tigtrur#inn Prutt Application is hereby made for a Permit to Construct ( ) or Repair Q(X) an Individual Sewage Disposal System at: 67 Autumn Drive Centerville .....--••..................•-•-•--•----•--....--•-•----.....--------------------------------_•-•-- --•••--------•--•--------••-........._...-----•-•-•-----•--...---•---....----------------.....---- Location-Address- or Lot No. Hx l a n d-------- Owner Address W J.P.Macomber Jr . Installer Address d Type of Building Size Lot............................Sq. feet Dwellin X No. of Bedrooms-.-.-..-..3 --------------------------------Expansion Attic ( ) Garbage Grinder ( ). aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity------------gallons Length.....-......... Width---------------- Diameter--.............. Depth................ 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....................................................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit--...---....---..... Depth to ground water........................ 0 Description of Soil........................................................................................................................................................................ V ...............•-••--•----------------..........--•------•---•----------Sand---&..Gravel-------------------------•-•- ••- ...........--....................................................................................................................................................................................... V Nature of Repairs or Alterations—Answer when applicable-.-.--..-..•................................................................................... 1-1000_ gallon pit . Packed in stone . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with I the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has bee issued by th, boar of health. Signed /O!/ ._10�12 9 3 . ...----- .. ... ._---...................--- .........--Dace-................ Application Approved BY C = ........ f�-D,iw �.— Application Disapproved for the following reasons: ............ ..................................... ........................................................................... .......... .................... . ........................................................................................... :........................................................ ........... ........................ _ Permit No. ........ .. ......... .. - .. Issued ..............:........................ D a te Date TOWN OF BARNSTABLE '-ILOCATION �.;,, ;y a2 SEWAGE # e .5 VILLAGE_ ASSESSOR'S MAP & LOT (o6 INSTALLER'S NAME & PHONE NO. / A�'c°ia►��� - )7r - SEPTIC TANK CAPACITY J coo 0 LEACHING FACILITY:(type) / (size) xloz .NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �/ 6 l 9 / �. I c t � a— -- �' --,:.. ,; � , .� h vv r 30.00 ..... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Application is hereby made for a Permit to Construct ( ) or Repair (KX) an Individual Sewage Disposal System at: 67 Autumn Drive Centerville --------------------------------•--...----...---._..._.....------------------------•-•-•••-------• --•--•••----•----•••••--•-•-•-••••----...----•----•--•---•-•-•---••••--••----•--•-••--•--......--- Location-Address or Lot No. Hxland.. .. -•...............••---------•-•--------------------••--•-••--•----•----- -•••••---•----------•-----•-----•-•---••••----•-•-.......--•--....---•-••-••-----........ Owe cr Address W J.P.Macomber Jr. j •--••---...-•------•-------•-------------•---•--•-•......-•-----•-----••-- --•---•••---------------......-••---...•-•••-.... •.. Installer Address Q Type of Building Size Lot............................Sq. feet I DwellingXX No. of Bedrooms.-___-_•__3 --------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ............ ......____- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a4Other fixtures --------------------------------------------------------------------------------------- -------------------------------------------------------•----- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter_..----------- Depth................ x Disposal Trench-- No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------_------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f74 Test Pit No. 2................minutes per inch Depth of Test Pit............ Depth to ground water........................ 9 •---••-••-•------------------•-•••-----•••-•--•-•••---••-•••-•-••-••••••-•------•-•--......••--•••--._.............--••--•........•...............•••-••••••. DDescription of Soil....................................................................--...-------------------------------------•----•----------------------------------..•..••••-••••--- Sand & Gravel U W ...-•--------------------------------------------------------------------------------------------------------------------------------•---------------------------•----------•-•---........--•-•-•••-•-- U Nature of Repairs or Alterations—Answer when applicable........................_...................___..___............................................ 1-1000 gallon pit . Packed in stone. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has een issued by\th boar of health. 10/12/93 Signed .. ��S�h ........ ............................ ........................................ Date Application Approved By (/t�(�g'',yv��" ! ..............._---....-..............----------.-----. -------- .......fh.m../..-3..77.�3 ....._....V `1....-- - - Date Application Disapproved for the following reasons: ........ ......... ... ...................................................... . .........---.................. i ......................................................... ............................. ......................................... . ........---..-. ................. .. ........................................ i Permit Na CC��. ... ... -_ .- _,f--sue.--- --------- Issued .........................................................Date..... 1.. ... Date ' -----.— --.— _.__—._ ---.—_.._---- ——— ._—_.--- —s—_.._.—.---_— THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH TOWN OF BARNSTABLE Clertiftrate of Q-11omplianve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by J.P.Macomber Jr. ....... h.,t:aiet 67 Autumn Drive Centerville ----------------------------------------------.------------..----...----.............-------------------.-------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......... - ... dated ___.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. i l DATE.............. t -.-...1.. ........ .. ............. ..--------- ----...._ Inspector .. _... ._.L........------ ..-.-........ ..... .................... .. - _.__-_,_,_,-,_-._„_,_ -------------------,._____-_---_:-------------------_--.--_- -_- THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH TOWN OF BARNSTABLE FEE 30...00 ............. ........ Permission is hereby grantedJ.P.Macomber Jr. -_ .- ---- to Cons t� ct ( ) or Re air X` an Indivi;heal Sewage Disposal System !; b1 Autumn Dpriv ,enterville at No street as shown on the application for Disposal Works Construction Permit No2,3,�y� Dated............................... ........... ............................ -_----------- ------------------------------------ DATE. f �-'- _-" j 3•-__•-••.................... Board of Health FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS No..__o.. ... .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® F ` HEALTH ....-.. ......................0 F...... � �®......n-..................._._. Appluation for Egaposal Works Tonotrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal so t: — = 0 ------- -- ' � Loc, 'on- r s a or Lot N - .�.. . _r_ _ .. Owner /- Address p I_ staller Address Type of Building Size Lot............................Sq. feet Dwelling lNo. of Bedrooms............ .......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures .......... -------- W Design Flow____________________ allons per person per day. Total daily flow__.._ gal lons. WSeptic Tank IL Liquid capacity-� __---gallons Length................ Width---------------- Diameter---------------- Depth-.--_---.._--__. x Disposal Trench—No.................... Width.................... Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area-_-_-.------_-____sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---------------------- ................................................... Date------------------------------------ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-_.--__-______--__-----. r3:q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_--__--_-____-.---.___ Description of Soil • • =------------------------------------------------------------ x W UNature of YZepairs or Alterations—Answer when applicable._____________________________•-:_---•-_..--_-_---._--__-----------_-.----.__.--------.-__--__-. ----•-------------------•--•--------••---------------------•--•------------••------•-------------•---••--•---------•---------------------••-----._---------------------------------•------------------- Agreement: The, undersigned agrees to install the afore d Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitar Code The undersigned f er 4grees not to place the system in operation until a Certificate of Compliance has e > sued by t of th. t Signed... . --•- •-•--•--•- -' •-------------• ................................ ate Application A , roved B _ Y.PP Y t / --�-��._... Date Application Disapproved for the following reasons:..................................---------------------•---•-••-•--•----•------•---••-•-•..................... --•-••---•-•---••...-•-----••----•-•-----•-•••-------------•-------•••••••••............=............................................................................... -----------------•--------•---- Date PermitNo......................................................... Issued---.................................................... Date ....T... ...............Gl-- No. f FE> ... .... ....... --•----- THE COMMONWEALTH OF MASSACHUSETTS !� f 14-1101 BOARDP.F .HEA_1,,,TH Appliration for Dispaiial Works Tomitrnrlion Vrrntit Application is hereby made for a Permit to Construct ( )a or Repair ( ) an Individual Sewage Disposal syt ,, �.. f ,' � - l� r .<, ____.._ .. _. .............. _ ........._. q Lo on A', s. or Lot N Owner Address w stall Address Type of Buildii Size Lot•__________________________Sq. feet U Dwelling-?No.No. of Bedrooms:_-_--____...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtulrg "� W Design Flow ________________ _ ________ ' gallons per person per day. Total daily flow...._ ___...__..___.._gallons. WSeptic Tank�Liquid capacity e ..gallons Length................ Width------... ------ Diameter---------------- Depth_..-_---..--.--- x Disposal Trench—No. ...:................ Width-_-•-___•___-.--_-.- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet._.....______....... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 0� Test Pit No. 2................minutes uer inch Depth of Test Pit.................... Depth to ground water____-__--_-_-_-_.------. Ix ........--- -- ----- ----- O Description of Soil----------------- �r '------ _--_---------------------------- V -----------•-••--------------•-----------------••--•-•-•--•----•--•--••-•-------•--••--------•------------••-•--------••••-••--••--•------------•-•-------------•-••---••---•-......-•------------------ W U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------. ---•--------------------------------•-------------•------------•-•---------------------------------------•--------------------------------------••----------------------------------------•---•-------.. Agreement: The undersigned agrees to install the afor�e4escribaed Individual Sewage,Disposal System in accordance.with the provisions of Article XI`of the State SanitaU°v Cgde= The undersned f her agrees not to place the system in operation until a Certificate of Compliance has been sue of Ith. Sign -------•-•-------•-----•----•--•... ............................ — ate Application Approved By.. ', ...... ............... ............... •--- -------------- ........ ` Date Application Disapproved for the following reasons-..................................-------------------------------------------------------------at.e.............. _ Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Pf HEALT , ' :............OF........., ' Trdifiratr of Tontpliaurr T I TO RTIFY hat the divi al Sewa ispo tem constructed ( or Repaired ( ) I stallei- at_ r { .. .. 4------ -- - ---- ----------- --------•--•------------------•------------------------•--------------•.' has been installed in accordance with the provisions of Article X_I of Jh,9 State Sanitary Code as described in the application for Disposal Works Construcrion Permit No____________________ ...................... dated.- £ ............. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DAtE................................................................................ Inspector-----------------------------..._..--------------------------•--••-----------•-•-•- THE COMMONWEALTH OF MASSACHUSETTS BOARD ,®F HEAD '" ............. oF... . No.__. ': FEE ------------- Rripo orb lanitrur#ton rnttt � Ad Permission ereby granted...... -- . _Z--- ----- �- -----�......------•---------- to Constr ( ) or epaif"� Indrvidual Sewage sposal stern ' ! .. Street / «p - as shown on the application for Disposal Works Construction � rt N tP�___ ated__.'__��------73 ---------- o - -- -------------------- oard.of Health DATE....................................... --------------------•- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS