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Home My WebLink About0101 AUTUMN DRIVE - Health 10 1 .A utumn Driv e Centerville A= 168-057 t S M E A D No.2.153LOR UPC 12534 amead.com • Meade in USA 1�- q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every page. City/Town 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key p to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX.145 Company Address CENTERVILLE MA 02632 seem Cityrrown State Zip Code 508-420-4534 S14297 Telephone Number License Number t 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�"ntenanct-�3)f on lte sewage disposal systems. I am a DEP approved system inspector pursuant�to;Section 'F51.340; Title 5-(310 CM 15.000). The system: , ® Passes ❑ Conditionally Passes ❑ F`aits ❑ Needs.Further Evaluation by the Local Approving Authority = £; 9-4-14 I Inspector's 146nature Date 1 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 conditionsW use. L�v q b�ll �l t5ins-3/13 Title 5 official Inspection-Form:Subsurface Sewage Disposal System-Page 1 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every 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: ® 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 MET ALL PASSING REQUIREMENTS AT 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 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 Title 5 Official Irypection Form Subsurface Sewage Disposal System-Form -Not for Voluntary Assessments 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every 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) 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•3/13 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 M 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every 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- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 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 Farm-Not for Voluntary Assessments M 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PERVIOUS PASSING INSP REPORT SYSTEM CONSISTS OF A 1000 GALLON TANK AND A LEACH PIT 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: 2012------------202 2013---------198GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commerciallindustrial 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 Title 5 Official, I spection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '( 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every page. Citylrown 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): TANK AND PIT t5ins-3/13 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 101 AUTUMN DR Property Address HASEOTES Owner Owners Name information is required for CENTERVILLE MA 02632 9-4-14 every 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: APPEAR TO BE ORIGINAL 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.): Septic Tank(locate on site plan): Depth below grade: 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 GALLON Sludge depth: LIGHT TO MODERATE t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every 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 Scum thickness LIGHT Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING AT LEAST EVERY 3 YRS 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 94-14 every page. Citylrown 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.): AT TIME OF INSPECTION TANK LOOKED TYPICAL FOR ITS AGE WITH SOME LIGHT CORROSION AND EXPOSED AGGREATE 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 94-14 every 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 NA 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.): NA 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 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.): AT TIME OF INSPECTION PIT WAS ENPTY WITH STAIN LINE AT AROUND 20 INCHES FROM INLET INVERT PIT IS 4 FT BELOW GRADE AND IS A 6 FT PIT 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 AUTUMN DR Property Address HASEOTES Owner Owners Name information is required for CENTERVILLE MA 02632 9-4-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Farm: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 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is CENTERVILLE MA 02632 9-4-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is required for CENTERVILLE MA 02632 9-4-14 every page. Cityfrown 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: 5FT + 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: ATTACHED PAGE 11 FROM PREVIOUS PASSING INSPECTION REPORT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 G M , 101 AUTUMN DR Property Address HASEOTES Owner Owner's Name information is CENTERVILLE MA 02632 9-4-14 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS PART C SYSTEM I FOILMATIO?i(continued) Property Address: i i ice``"t Date of Inspt6fio s: f+ . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the swage disposal s�t rn includi 3a ties to at least two perm-anent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. I I 13 j Gt iI Ay j . -C--7 ! ! , r .3 ' /-� •t e i i 10 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS STBSUISI ACE SEWAGE DISPOSE SYSTEM INSPECTION FORIM SYSTEM IN i NATION(continued) Owner: l`&Q,,;,�_;,_ cr Date of Inspes€ioa: ;/X--Z s- ' r SOIL,ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required). If SAS not located explain why: 3✓ leaching pits,number I leaching chambers,number: jeacrilwg gaiienes,t3umber: leacliinQ trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: irinovativrJalternative system Type name of technolog- Comments(note condition of soil,signs of Hydraulic fail€trer level,of panding:damp soil,condition of vegetation, etc.): t A lA %s.3SYvvi.S: r> tcessroof must ae pumped as part Q!mspecuon�:iecate on site plan') Number and configuration: Depth—top of liquid to inlet invert. Depth of solids layer Depth of scum layer: Dimensions of cesspool: IniutCaiivai of goiii3Utitldi"f% %£llfli3h U, L�6 bc$) Corn ments(mote condition of soli,signs of-hydraui€c failure,level of ponding,condition of vegetation,etc.): PR1VY14J(-'-'(locate on site plan) Makerials of construction: Dimensions: Depth of solids: Coa umieaits(note cJiiiii6uia.vi_iilli,Sa91"IJ of laydrauldl 1;1333 7 l vet i3d�Lt23i.i1lig,condition-Of 9 Page`I I of l i OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBS URF4,C SEN AGE DISD0Q A 1--SYSTE]k SPEar_.ia TON FORM PART C SYSTEM INFORMATION(continued) Dr a r�reex• a op—,Add e—, - Date of Inspecewn: f� 'c` r/ STI'E EXAM Slope Surface water Check cellar Shallow wells _ t Estimated depth to ground orate: ieet Please indicate(check)aH methods used to determine the high gro&-d water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting propertylobsezvation hole within 15€3 feet of SAS_) Checked with local Board of Health-exwiain: Checked with local excavators,installers-(attach d4cu_mentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: i:��,}i�.CT i4.i:,L;7-,i Ci {�L;. '-'fit% '—°s % ife�, j� �:..� t I] III i COMMONWFALTROFMASSACHUSEWS EXECUTWE OFFICE OF NVI ONMI NTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 05 SOW, TIME 5 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM FART A CERTIFICATION Property Address: ' Owner's Name: Owner's Address: b Date of Inspection:_r ,//,ram Name of inspector.(pleas=print) . Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA , Telephone Number. 150111 77S—t3776 CERTIFICATION STATEA ENT 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 funahm and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section I5.340 of Title 5(310 CMR 15.004 The system: E/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: ! � The system inspector shall submit a copy of this itrspectiou report to the Approving Authority(Board of Health yr DEP)within 30 days of completing this kgxxtiom If&--system is a s system or has a design ttow of 10,000 gpd or greater,the inspector and the system owner",submit the reptrtti im the appropriate regional office of the DEP.The original should be.sent to the system owner and copies sent to the buyer,ifapptieable,and the approving authority. 'Notes and Comments `•••This report only describes conditions at the time of inn and tinder the conditions of use at that time.This inspection does not address how the system will perfwm 16 the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page i Page 2 of I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SMWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: W' 1 &24- -\t-, Owner: Date of lnspection: Inspection Summary: Check`A,B,C,D or E/ALWAYS complete all orSsetion 1) A. System Passes: t/1 have not found any information which indicates tltat any of the Wure criteria described in 310 CMR 15.303 or in 310 CNR 15304 exist.Any failure criteria not evaluated arc.indicated below. Comments: a 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 infrltratioa or ex€itratimt or tank failure is immim nt System wi11 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 bacimp or break oat or high static wane[level is the distribution box flue W broken or obstructed pipes)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 moved distribution box is leveled or replaced ND expht n: The system required pumping more than 4 times a year due to broken or obstr%xied pipe(s).The system wd I Pass inspection tton if w r th approval of the Hoard of Health): broken pipes)are:replaced obstruction is rt:mavod ND explain: f Page 3 of l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10\ %v Owner. V--eCiice.: ci "s�s� Date of laspectioa: Y" doe,4 G 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 L System will pass unless Board of Health determines in accordance with 314 CiViR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety arid-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 fait unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of 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 It10 feet but 50 feet or more front a private water supply well" Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic 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 in be attached to this form. 3+a Other. 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner- Date of Inspection: , D. System Failure Criteria applicable to all systems: You must indicate`des"or"no"to each of the following for all inspections: Yes No _ 2 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 is 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 1901eet of a surface water supply or tributary to a surface water supply. _ ✓ Any portion of a cesspool or privy is within a Zone I of a public well. ____ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private AW= supply well with no acceptable water duality analysis.(This system passes if the well crater analysis, performed at a DEP certified laboratory,for colifortn bacteria and tiolat'He organic compounds indicates that the welt is free from pollution.from that facility and..the presence of ammon"ta nitrogen and nitrate nitrogen is equal to or less than S ppm,,pmddedi that as other failure criteria are triggered.A copy of the analysis must be attached to this form-1 (Yes/No)The system fails.l leave determined that one or more of the above failure criteria exist as described in 314 Cb4R 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: /\j JA To be considered a large system the system mustserv.e a faciffty with a design now of 19,009 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large system in addition to the criteria above) yes no the system is within 400 feet of a surface dcin dq&water,supply the system is within 200 feet of a tributary to a surface drir&m&water supply — the systertt is located in a nitrogen sensitive area(Interim Wellhead Prolection Area—IWPA)or a mapped Zone I of a public water supply well If you have answered"yes«`to any gttestiQu in-SectimE thtsystem it considered a sigttil"mant threat,arr answered. "yes"in Section D above the large- significant threat under Section E or failed under Section D}shalt upgrade the system,ire acardancc r-i&,3 C:0 CMR 15.304.The s3item a%-,mar should contact die appropriate regional ot`hce of the Department. 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART B CHECKLIST Property Address: �c i �)A' 4 - CC77-7— ti- i i owner: !=C' 7r1CS C!.. Date of Inspectlon: Check if the followinIX have been done_You must indicate`eyes"or"no"as to each of the following: i Yes No Pumping information was provided lay the owner,occupant.or Bow of Health ✓Were any of the system components pumped out in the previous two weeks g ►` 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 plazas of the system obtained and e tined?(if they wem not available trots as N/A) _ Was the facility or dwelling inspected for signs orsewage back up? Was the site inspected for signs of break out? ✓ — Were all system components,excluding the SAS,located out site were the septic tank manholes uncover f due interior oftfte tarok meted fear the condition of the baffles or tees,material ofconstructiFan dimensiom depth of liquid,depth ofsludge and depth ofscums 7 Was the facility owner(and occupants if diluent from owner)provided with informations on the proper maintenanci of subsurface sewage disposal systems? The size and location of the Soli Absorpdo€e System(SAS)ore the situ 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 Pan C is at issue approximation of distance is unacceptable)13 10 CMR 15.302(3)(b)] 9s F.. 5 Pace 6 nr 4 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS a$iu1i[Aasi:yaasAvSi-au v a v T i.s;FR w �e E Akp 4 r%YAX!LT a FART C SYSTEM INFORMATION Property Address: V)i ;kjl t-;-\ ,Vale of Inspection: a=ao FLOW CONDITIONS RESIDENTIAL _ _ ti Niitit.°-i.�.r of:iw—nib(iiQaivii.�_ a�'".iiaa.waa vI iii'. iiia tatiivai): DESIGN flow based on 310 CNIR i 5.303(far example: I i 0 gpd x#of bedrooms): 330 6 Number of current residents: -4- oes rreidence have z azr?4zar errsrssEa r EerGz€sr-sE ,-�: Is laundry on a separate sewage system or n*tw (ifyes separate inspat€oo rewired Laundry system inspected(yes or Seasonal use:(yes or no): NV _ c':{{ass. •�.�. _ Water='-nettcr?=C.33-gs,91 av="--='' vast 2 y [i� -'a ia�i`�7's'' Sump pump(yes or no):,W - ;. Last date of occupancy. €t,rf&,,V Type of establishment: ! " ✓-r Design flow(based on 3I0 CMR I5103): gpd Basis offdesign flow(seatslpersons/sgft,etc.): '�rbID3b Sr9+ 9is ra Vms or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 3 system(yes or no):_ Water meter readiries.if available: Last date of occupancyluse: OTHER'(describe): GENERAL IINFO"IATION Dumping Records Source of information: r'u p r°d s w esrs�`.�.iirr�ES`^-�8•i-Rs�€�",R� If yes,volume pumpetV. gAlotts—How was quantity pumped Reason for pumping: TYPE OF SYSTEM L11"Seplic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —shared systetts(yes or no)(ifyes,attach prenous tupecdaff eea order ifany) _InnovativefAltemative technology.Attach a copy o("tlur current operatio€t,and maintenancc contract(to€re l2Yi�9d3P4t from s1[4Qm 4'f1Vn Pr) Tight tank Attach a copy of the DU approvaj Other(describe): APproxim-ate aa€e of alt comp—m—cants, aLe%e-a o. f ifkaav: €anv&vaurcet of form—a leem ig�ia'�¢a�3a a. iias.$� • 'a 3' i' '.a r=r :/Vi !F ---� ESSMENT. PAICr C i is a A.e**a i:r air 169 star-* A s UM — e z BUILDING SEWLR(fie im site jdan) Vcph bcb,w tea&.. S " ' S Mmais Of last i"M ✓/$9 Pvc_W3(CAP12 n). Diume fient Vials c svmy wCH w Micrwe� 3EPTIC T K;=(locak on sns DAaft) Dcplb bellow g$at': f a Maiuial of con I MEaittrctc •_mot Sald:tgDa;s_I8uD3ctDa� itt —201ss(czphu) If tank is costa(Dist abs:_ Is age cv'feincd $Cestiiicate of Cu Dtaftce cettlftt:atc) s gt Iw):_,attach a cull}tjt- Ditncnsions: Skidgc depth-. Distsncc Got'top of sDttdgc to bmuni of outict icc at batik: 3°s Sr,m titicD;ncss: 19" D3istanec from top of scion to soli of uultet tcc of ballle. _AD Distancc ffant bonant of scuni to batiom of ttct tcc at bailie: /,Jl_i"ow wcfc dimensions dctctmintd: Cam Cummcnts tun pumping fecainn+catatations*Hiles slid outict tcc ar bank conditit,n,sU VLtiu at inlcph j,liquid is vcl% as tasted to outlet invest,evi&n_cc of leakage,cic_): '1 b•�aJ � 3gt ( e. ogosa, SOW- a , CREA56 TRAi': 4ucalc on site lusts) iielttlt bclow grade;_ hiatclial of consttuciion; wttctctc Metal`11beiglass__pulycdtylcitc 011itf (cAplEitt�; — Ilitncusions, Scum dtickncss: t`Distaacc from top of scum to Cult of uutict tcc of baillt:: _ Vistancc Gotn bttttottt of scum to bottom of outict tcc or baiik: bale of last pumping: Cununents(on pumping teco►tuncltdatitnts,ittiet and uutict We ut baftie cotidate:t,sttwwal wi%tit?,liquid Icv(:li as tc"'cd to oullct ittvctt,Cvidcttcc of kaka fc,ctc.)_ 7 ,'age OFFICIAL INSPECTION FORM-14()T RM SMAGE DISPOSAL SYS-1-L-NI INSpvc-� &,%- A I ION 11,70juNI ilk tFT c Sl'STLAI INFOILAIATION icuniiliutd) rtQPctlyAdUJrcjj: )U1 /Aul-L"("e\ X 4N v—V ! t L Owner: Dolt of Impti'don: TIGHT or HOLDING TANKVW'4.'_L1 .......vz inspectiull)(jur ate Un site flan) Dpill below grade: hl"Iclial of comtruction:--cullUcte Design blow; Mann present(yes of no): Alarm level: Aland ill kvL, tycs of 11U). bale of last pumping: Cullifistnts(cunditinn_r ncilcs.Etc-): DISTRIBI I*r,,(3N UG\: if llfcscllt Must be opctict.1)(lotaic oll Silc j.jgjj) Dcptb or liquid level above outlet iIIvcf 1: Cut 11111cfas(note If box is IcvcI and disl#i C., akage inlu or out of bux.c1c.)_ cv:dcUUi:iu4ids catryover..ally evidence of PUMP CRAMULK:f- 4(lUEatc on silt plan) Pumps in vvwkirbg older(yes of IIU)- Alanns in%voiking order(yes of 110). CU111111C 1115(flulc condition Ur puffill IL lialledc I EmOa;... -f pun-ps =d CK.Y Page 9 of I I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSItM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Tip cii-'rill fii�@$.'+� 10' f�j � i 1%Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): to"e (locate on site plan,excavation not required). if SAS not located ex".1affi why: .T3'p" leaching pits,number: leaching chambers,number leaching gaiieries,number_ leaching trenches,number,iengui: leaching fields,number,dimensions: overflow cesspool,number: inn ovative/alternative system Type/narm oftechnology- Comments(note condition of soil,signs of hydraulic failure,level of pondin&damp soils condition of vegetation, etc.): c3 11 ✓q l3 4- --.w..J` C .tl� � ^�,.. �_,ii4s . - Lam. 3' 'L rs. 1 tI /s.i;L•_ CESSPOOLS: • Icesspooi trust€c pun led as part of utspectiost locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of sblids layer: Depth of scum layer: Dimensions of cesspool :1edication of ga u`t&watra inflow es or t�:. Comments(note condition of soil,sighs ofltydraulic failure,level ofponding,condition of vegetation,etc.): PRIVY A(locate on site plan) Materials of construction: Dimensions: Depth of solirlc- C`Jr y^.tent5 Ott;to CL't�dti.'.^,;�^,f5isiy SigaiS fuy uaiilii ati$iis,i�a�a of cuing,c3i.ditl i.of veg£tad n,etc_): Page 10 of i l OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS PART c SYSTEM INFORMATION(continued) Property Address: f I t Date of Inspe$tion: -4n'v- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including,ties to at least two permanent reterence landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. t 6 F itJf1 A y r 17 1 G�;,-ri4/ ,f 9` lQ 'Page I I of I i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW AGE DISPOSAL SYSTEM INSPECT'ON FORM PART C SYSTEM INFORMATION(continued) Property Address: Owl er. 0 Date of Inspection: 1-�C7 ` SIT£EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground waterJ fee-, 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 propertylobservation hole within 150 feet of SAS) Checked with local Board of Health-explain. Checked with local excavators,installers-(attach docu_cnentation) Accessed USGS database-explain You must describe how you established the high ground water elevation: 1"'rN-" ' a 11 i Town of Barnstable �pF THE lq�� yP o� Regulatory Services STABLE, * Thomas F. Geiler, Director 9� S 1639. `00 p,E Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTIC\Disclaimer Private Septic Inspections.DOC' kg - � 7 No.... Fxs:- ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE pV tratiott for Uiinpa! l Wnrk,i Towitrurtiou ramit Application is hereby made for a Permit to Construct ( ) or Repair (V'�an Individual Sewage Disposal System at: qq . 11 ...... . ..U_.�....UTU�+!1 0 �� Location-:Iddre s or Lot No. �4------------•----------•----- --- ,e z- .. Owner Address .........l_• - oua..co---- .............................................. .1 Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms------ --------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p-' Other fixtures .... .._ W Design Flow_________________________________ _________gallo s per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity _._____._. allo Length_--__-___--_ Width---------------- Diameter..---._...____. Depth................ xDisposal Trench—No. .................... i th----_:.__-._______-_ Total Length-------------------- Total leaching area--------------------sq. ft. ...__..... Depth below inlet.................... Total leaching area._..........._....s ft. � Seepage Pit No..................... Diamete ._._._ .. p g q, Z Other Distribution box ( ) Do ing tank( ) Percolation Test Results Perfor ed by. ------------------------------------------------------------------------ Date...................................... a Test Pit No. l................minutes per inch Depth of Test Pit._.__..____________- Depth to ground water---________._______----. yr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._-____--_--.--____. 9 --------------------------- -------•----•-----------------------------•-•-------•-----------•-_...-•......................................................... 0 Description of Soil........................................................................................................................................................................ V -----------------------------------•--•-••---------------------------------------------•--•--••.....--•-•------------------------------------- ---------•--------------------------•-•---------•-------- VW --------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- Nature of Repair Alterations—1�nswer when applicable._ - 6..LP-G ---- ---------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board of health. Signed 6i�/ ......... . .� `� 9 Dace Application,Approved By -------( k ,-- --------------------------------- ------------------------------------------------ 3------ ' U Date Application Disapproved for the following reasons: .. ................................. . . ........................... .... . ................ -------------- -----------------...._...----------------------------------------------------------------------_----...---------------------------------------------------- Dace Permit No. ....... J�-...=` -� ......... ..... Issued 3="---� ... .S -------.._. Dace l THE COMMONWEALTH OF MASSACHUSETTS BOARO� OF. HEALTH TOWN OF BARNSTABLE Appiiration for Di-tipini al Works Tvastrurfivit ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: • <�_ .<... UT.-CJN. Location-Add re s ...... �?�L l rLot No, — Owner Address Installer Address Q Type of Building Size Lot............................Sq. feet V Dwelling— No. of Bedrooms------______--------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ------------------------ --- No. of persons-------------------_-_.--_ Showers ( ) — Cafeteria ( ) d Other fixtures ...... — -: --------------------------------- ---------------------------------------------------•--------- W Design Flow----------------------------------�.-gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity ----- gallonsLength_ Diameter--..------------Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------------_--- Diameter--------�_s.....__._. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Doffing tank ( ) Percolation Test Results Performed bY------------------------•---•••-••------------••......••--------•----•-.. Date........................................ Test Pit No. I................mmutes per inch Depth of Test Pit-.-_--_-_____---- _ Depth to ground water...................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit--.__-----____-__._. Depth to ground water........................ lx ....----•------•----•...-•---------•------------••-•---••--•-••-•-----••-•-•--......•--------•-•............................................................. 0 Description of Soil........•-------------------------------------------------------------•---------------..----•------•••--------------•------------•-----•-----•-•-••--•........-------- U .............................................................-........................................................................................................................................... W UNature of Repaiirs_or—Alterations—Answer when applicable._ ��_/_ '�1�� 1J.�Y_..�_ __S/ e; Agreement. TM The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has -been �issued by the board of health. Signed . ---- L — -... .-----7 . Date A PP lication.APP y roved B ..........I .......... ..H-�....-..�-------------------------------------------- ------------------------------------ . ... Date Application Disapproved for the following reasonf: .._......._... ........ .........................................-, .. . . ....... -- c� Date Permit No. ......./ ' - ( ? -. ................ 7 _............:... Issued -............._._7..-- ' Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�elr#ifiett#e of C ontplian>ce / THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by ------------------------------ ---------- .C..t�. .._ ---- ---------------------....------_-------------------------------------. ..-------------- ------------------------------ ----------- Installer at .../_G../ A L7 a L1 1-----Z)./T..........._... r /� '� 1�.-------------------------------- -------------------------------- ------------------------ 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. .?.ter _-.. ----------- dated .... ..: .-..9. - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �-- DATE..... ..... ................. 1�..... . � ector� --- ,...... . f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... S__.: .7G FEE....�.__ Dios oal oxko Hutto#t` r#i�ttt hermit Permission is hereby granted.............. ...GL....... to Construct ( ) or Repair an Individual Sewage Disposal Sys em atNo. / � .1< .....--- �`Pti ........................... .......................................... Street CC>.�_ zz as shown on the application for Disposal Works Construction Permit Nol_:5_.-.J7K- Dated------ .-- / _ c� (-+rd of Health DATE...................................... J-----------------•-•. FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS TOWN OF BARNSTABLE p LOCATION 1 G 1 A 1 U y-i /,1 Dr?- SEWAGE # VILLAGE Ce-A)T' ASSESSOR'S MAP&LOT —,0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 2 1 � (size) �Y NO.OF BEDROOMS t a BUILDER OR OWNER I P-" ad(_._O Lo AA 734 PERMPTDATE: 73. ) COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) r Feet Furnished by r - -, � � � �� c .� a /!�a° �� N..... � ---•-- Fss.....1.. ........Nw......... THE COMMONWEALTH OF MASSACHUSETTS BO.*R,,D OF HEALTH ......... ... .................OF.......................................................................... ..-------- Appliratiou -for M_qp Qsal Workii Cnl tuarurtiou Vrrmft Appica on is hereby made for a Permit to Construct (e j or Repair ( ) an Individual Sewage Disposal System at: -•-o --.�...••---••••-- ---------------------- Lo2' n-Address -----••------.or. LoY..o..- � � • .:. ` . pH r Address ----: A�---- ---- l s ler Addr ss dType of Building Size t._ ......Sq. feet rooms.._______ ________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ._ --_- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) U Dwelling- io. of Bed Q' Ott r ure W Design Flow_____,�P ____ __ _______ll______.____gallons per person per day. Total daily flo _ _. ____-_--_-._.-......gallons. Septic Tank—Liqui capacitvl�--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---------------------------------------- aTest Pit No. ---------------- per inch Depth of Test Pit-------------------- Depth to ground water--------.----.-._-.----- G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 9 = -•----...----•----- = Ft t -....._ - r --- , Description of Soil - I . r� �. J� A /D ---------------tvl.'--�- V ------------------------------------ ---- ------ �/1----------� '2 f:ee.Z` i >_. r �—t .+ 1-.e/fit - '`f; W ---------------------------------------------------------------------------------------- ------------------------------------------------------------ --------------------- --------------------...__. VNature 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 Article XI of the State Sanitp-y-o —The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha/s eei�r sued by the o �'of heAh� y Signed. .. i� - ---- 1�� / / Date Application Approved B i/% !�'_ n../ _ //.. .�_�__. PP PP y----- f:•----• ............•.. ` /Date Application Disapproved for the following reasons-........................- ....................................................................................... ----------------------------------------------------------------------------------------------- Date Permit No. f ----------••......•----- Issued - 7 Date l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _._. ... . ..........OF..................................... . --.....I..........................---- Appliration -for Uttipmal Worku Tutuarurtion Permit App 'ca`on is ereby made a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst t• - '--• - -- ----------------------------- ---- -- . --"-• ------------ Lo n_Ad res or t 'o. 41 .--- -------- ••• . .......... _ Ow er Address W ns ler Ad ss �•�.� Q Type of Building Size t__ Cs_a_(d_______Sq. feet U Dwelling o. of Bedrooms__._____ Expansion Attic ( ) Garbage Grinder ( ) .-� p, "Other—Type of Building .._. ____ No_ of Expansion Attic Showers ( ) — Cafeteria ( ) Oth r fi_ ur �y ...---------•----------- W Design Flow.... __gallons per person per day. Total daily flovatt_ _. gallons. 94 Septic "Tank—Liqu capacity/.gallons Length________________ Width-____-.--...._.. Diamete _____...___.____ Depth.._-__-__-__--. xDisposal Trench—No_____________________ Wid,�t.h�•_� _______ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit'No..................... Diamete� _ Depth below inlet.................... Total leaching area_..__...__._-___..sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolat ols Test Results `; Performed by.--------------------------=----------=--------------------------------- Date--------------------------------------- Test ) it No. I.............___minutes per inch Depth of "Pest Pit------ ____,__-__-_ Depth to ground water________________________ (� Test Pit No. 2................minutes per inch Depth of Test Pit-----_'__.__________ Depth to ground water__.____________-_____.-. --- - ----- ---- escription of Soil •Q• ��' •"ss s'�? '� r - 04.— *iC s,r �•J / U -•------•--------•- •------•------ - - ---- 7!;.7...`......a 'n -- - fir -•----•'•-••-•-• •-----. . 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 Article XI of the State Sani o — The undersigned fur ,'er,agrees not to place the system in o eration until a Certificate of Compliance h s sued by tV,.$o f �'' Sign .... ''---- --'- / Application Approved By.--- . •'--- _ _ - -r:...............�"'".'' ----.77 at ' `t .� �•f � � ate Application Disapproved for the following reasons:-------------------------`_---_--------------------------------------------------------------•----____--------•-- Date ` °� Permit No. ;..._. Issued.--------r•- --•-.... r Date, � _ ` THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH OF........ .. .......................................... �rr�ifirate of 01.1111implittnrr HIS IS TO PCIFB at the Individual Sewage Disposal System constructed �<or Repaired ( . ) b ---- --------- --- tall has been installed in accordance with the provisions of Article.XI of�o,�f.yT�he State Sanitary Cod as described in the application for Disposal Works Construction Permit No-------��-• ______________ dated-��%/7X.................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTIZV D AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY. t� DATE----'------------- . Inspector. �,-. 1 !�M - L._!••? Iti THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH Lf" .... .. ...OF........ !�1,,................... ...................-*;� No>,�• - -•-•• FEE-- _(.l -_--------• ' ork,� o �tr#ion �rrnti# - Permission ereby granted-'.. 4. - ----•- '---------------------------'-------------------------•----•--•'--•--••...----•- to Constru (f r Rep ' n In i �1 Sewage spo. Syst y�`T�t • �. � ........................................ .. tat No---- - -------- -- '---- ----- ----------- - •------- - �-- --- Street as shown on the application for Disposal Works Construction Dated... ............ oo . . -------------•---- _ � � ard ofHealth .n- DATE-- --=-��--'.--� ---�-- -�---------------------------------•--•-• FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS , y a j S 4 LOA�T_I0� WAGE PERMIT N0. 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