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HomeMy WebLinkAbout0147 BEECH LEAF ISLAND ROAD - Health 47 Beech Leaf Island Road Centerville A = 187 063 004 S M EAD No. H163OR UPC 10259 smead.com • Made in USA V&CYC(,�a -e Sq /�Z & 'I Commonwealth of Massachusetts 19-7'0&3-00� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7M ,. 147 Beech Leaf Island Road Property Address Syivia Forester ? Owner Owner's Name ' information is required for every Centerville MA 02632 10-20-17 page. Citylrown State Zip Code Date of Inspection 71 i 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 computer,on the form S/ OF iygs use only he tab 1. Inspector: key to move your 0�, S cursor-do not x�:• N James D.Sears =g: JAMES m kee the return us Name of Inspector =v y *'. co Capewide Enterprises Q Company Name ���l'• � � o°\�� 153 Commercial Street 'p�F S I N SP�G��`°�� Company Address Ill Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S 1623 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 10-28-17 I ector'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 SyststeSm•Page 1 of 17 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and pit. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts L r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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.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 °M 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 is less than 6" below invert or available volume is less than '/z day flow PIT t5ins.doc•rev.6/16 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 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 E] E] 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is Centerville MA 02632 10-20-17 required for every page. Cityfrown 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.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 °M 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Tank D Box and pit. Number of current residents: 1 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 2015-32,000Gals g ( y g (gp )) 2016-23,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present 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.doc•rev.6116 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 ;M 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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: 1995- permit#95- 141. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 7' - 10" 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.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 7'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: 1500 Gal. Precast Sludge depth: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 NA 1 Scum thickness 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 How were dimensions determined? Asbuilt-Plan-Tape 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.): Tank at working level. Tank at 7' below grade w/inlet cover at 8". No sign of leak age or over loading. 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.6/16 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 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. Cityfrown 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 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box located and inspected w/camera. Clean and solid. 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 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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.): Leaching is a 4' H-20 pit w/4' stone. Pit at 7' below grade w/steel cover at grade in drive way. Pit and wall's look like new. 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 I Commonwealth of Massachusetts _ - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 r R°a( a t a 3 �� 3 t5ins.doc•rev.6/16 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 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na 13'+ Estimated depth to high ground water: 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: 11-14-85 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: T.H. on Design plan 11-14-85 13' no G.W.. Bottom of pit at 11' below grade. Bottom of pit at 2' above T.H. Depth. Lot on a hill above main road. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 147 Beech Leaf Island Road Property Address Syivia Forester Owner Owner's Name information is required for every Centerville MA 02632 10-20-17 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 -\ COS IA40?NTiYEALTH OF-KksSACHUSETTS y` EXECUTIVE OFFICE OF ENVIRONMENT_ALAFFAI:RS. �I DEPARTMENT OF.ENVIRONMENTALTROTECTION N�_�.:�� TITLE 5 OFFICIAL INSPElCTIO t FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I0G 17 0 GPI Property:Address:. P / G'c0 �� Lt�C/L �' Owner's Name: f g Owner's Addressr q7 sRPPPA Date of Inspe ion: _ cat Nam f 1nsp rto.. (pi.ease Print � • r lvr' ` T. Corm�any Na e: 1. iVIa4Lna Add < } in Tel Lone NQ44-ber:_ ,4Q 82 :2 2Z. ej %;gg CM'TIFI I ATION STATEMENT _i cqf ry that I have personally inspected the sewage disposal system.at.this address and that the information reported E«... belo�+a is true,accurate and complete as of.the time of the inspection. The`inspection was performed based on my training and experience inthe 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(3.10 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation`by the.Local Approving Authority _ 11s I.uspector's Signature:. ^------ Date: 16116 ✓c1�, The system inspector shall submit a copy of this inspection report to the Approvin Authority(Board of Health or DEP)within 30 days of cornpleting 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 systern owner and-copies sent to the buyer, if applicable, and the approving authority. v Notes and Comments *%*This report only describes.conditions at the time of inspection.and under the conditions of use at that time..This inspection does not addres5low the system will perform in the future under the same or different conditions of use. Title.5 Inspection Form E/1572000 page] x _ Y c_ Cam— Page 2 of l 1 OFFICIAL INSPECTION FORM'-NOT FOR VOLUi°i I' RY ASS�SSIYIENTS r SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION ]FORM' PART A CERTIFICATION (continued) Property Address: Y.7A k,!� 2 yI 0 � Owner:. i Date of In pection: hispection 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 CNIR 15.304 exist.Any failure crrteria.not evaluated are indicated below.. Comments: B. , System Conditionally Passes: One or more system components as described:in the "Conditional Pass"section need to be replaeed'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,NjI D)in the for the following statements. if"not determined"please explain. The septic tank is metal and'over 20 years old*.or the septic tans{(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent:System will ass inspection if the _ Y P P 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 thatthe tank is less.than 20 years old is available. . ND explain: _ Observation of sewage backup or break out or high static.water.level in the distribution box due to broken or obstructed'pipe('s)or due to a broken, settled.or uneven distribution box. System will pass inspection if(with approval'of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced , ND explain: A , The system required pumping more than.'4 times a year due to broken or obstructed pipe(s).The system will pass.inspection if(with.approval of the.Board of Health): broken pipe(s).are replaced obstruction is removed ND explain: ,t �4 r i age 3 of 1 i OFFICI L INSPECTION FORIM1 NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEV/AGE.DISPOSA.L SYSTEM INSPECTION`FORM PART:A CERTIFICATION(continued) Property-Address: y 1�L Owner:" a Date of`i�spection: a C. Further,B'ynluation 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:p2ss unless Board of Health determines in accordance with 310 CIMR 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 System will fail unless the Board of Health (and Public,WaterSupplier,if any).determines that the system is functioning in a manner thaf.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 Zone I-of a.public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system.has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply.well**. Method used to determine distance **This system passes if the well water analysis;performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is.fi-ee from pollution from that facility and . the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3. J Paae 4 of.11 OFFICIAL.INSPECTIONFORM-..IVOT FUR YGLUl?dTaRY ASSESSMENTS SUBSU:RFAMSE"WAGE DISPOSAL.SYSTEM INSPECTION.FORM . PART A CERTIFICATION(continued) Property Y Address:- P Y7 azeA Owner: Y Date of Inspection: 7-0 D. System Failure Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the.fo.11owing for all inspections. Yes No Backup of sewage into facility or system component due to.overloaded or clogged SAS.or..cesspool Discharse or pondin of effluent to the.'surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool y Static liquid level in the distribution box above.outlet.inver'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 Y day flow Required pumping more.than 4 times in.the last year NOT due to clogged o -obstructed pipe(s).Number f o times pumped y VAny portion of.the.SAS,cesspool or privy.is.below high ground water elevation. Any portion of cesspool or privy is within lMfeetof a surface water supply or tributary to a.surface water.supply. . . Any portion.of a cesspool.or privy is within a Zone 1of a.puolic 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 1.00 feet but areate.r tlian.50.Leet.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 colifor.m bacteria and volatile organic compounds indicates that the.well.is free from.pollution,from that.facilityand 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.} (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The.system owner should contact the Board of Health to determine what will be necessary to correctthefailure. ' E. Large..Systems. To.be considered a large system the system must serve a.facility with a design flow.of 10,000 gpd to 1.5,000 gpd- You must indicate either"yes'' or"no"to each of the following: (The following criteria apply to large systems.in addition to the criteria above) yes no _ the system is mithin 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 SectionE 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 3;10 CMR 15.3 04.The system owner should contact.Y the appropriate regional office of the Department. Page of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURF_ CE'SEWAGE. DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Y T Owner: 011 ' Date of 1 spection: c� cp Check if the following have.blen done.You must indicate"yes"or"no" as to each of the following Yes. o lumpinz information was.provided by the owner, occupant, or Board of Health _ZWere any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period ? _L Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans ofthe 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 ? ' V _ Was the site inspected for signs of breakout? 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 detertnined_based on: YZeso Existing information. For example, a plan at the Board of Health. Detez-mined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CI R 15.302(3)(b)1 5 { Page 6 of.11. OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORA PA`RT.0 SYSTEMmINFORIqATIOIN Property Address- Owner: � Date,of In ection: (� FLOW CONDITIONS RESI.DENTIAL Number of bedrooms.(design).- Number of bedrooms.(acrual).: 3 DESIGN flow based on 310.0 MZ 15.203 (for example: 11.0 apd x T of bedrooms): Number of current.residents: % Does residence have a garbage grinder(yes or no Is laundry on.a separate sewage system��(y� or no):A&[if yes separate inspection required] Laundry system inspected( e .or no):��1.(� Seasonal use: (yes or no): O Water meter readings, if ava able (last 2 years usage,(gpd).): � �,� ' Sump pumpes or no V Last date of occupancy: COrYIMERCIAL/INDUSTRIAL.A/0 Type of establishment: Design flow(based on 310 CMR I5.203): apd Basis of design flow(seats/persons/sgft,etc;):. Grease trap present(yes or no);._ Industrial waste holding tank present (yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings; if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 4,411 rn Was system pumped as part of the in pecfio yes or no): If yes, volume pumped: gallons --how was quantity pumped determined? Reason for pumping- TYPE OF SYSTEM ptic 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 fxorri system owner) _Tight tank _Attach a copy'of the.DEP approval .Other.(describe): proximate age ofA comrponents, date installed(if known)and source of information: Were sewage odors;detected.when arriving at the.site (yes or no): .Page 7 of] 1 OFFICIAL INSP ACTION FORM—NOT FOR'VOLUNTAR'Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION TORM . PART C S STEM.INFORMATION`(continued) Property Address: Owner: ZI ti Date of In. pection: BUILDING SEWER(locate on site plan) A) Depth below grade:' Materials of construction:_cast iron _40 PVC_other(explain): Distance-from private water.supply well or suction.line:_ Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: /ocate'on site plan) � � � Depth Below grade: �� Material of construction: concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:._ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of'outlet tee or baffle: 3 Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scup, to bottom of outlet tee or baffle: How were .dimensions determined:. Comments(on:pumping recornmendKtions, Net and outlet tee or baffle condition, structural integrity, liquid levels a related to outlet invert, evidence of 1 akage etc:): y pea dl GREASE TRAM (locate o-ir site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to too of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee orbafrle: Date oflast.pumping: - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert; evidence of leakage, etc,.): Page 8 of 1.1 OFFICIAL INSPECTION FORM.—NOT FORYOLU" i'I ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM- INSPECTION FORM PART C SYSTEM INFORNL.,kTION(continued) Property Address: 24ozeA � Cf Owner: v Date of I spection: ;&0(ly TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(loc.ate on.site plan) Depth.below grade: Material of construction: concrete metal fiberglass polyethylene other(explain):. Dimensions: Capacity: gallons Design Flow: gallons/day Alann present.(yes or no): Alarm level: Alarm in working.order(yes or no).: Date.of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: if present must.be opened)(locate on site.plan) Depth of liquid Ievel above outlet invert:. �Al2Aej Comments (note if box is level.and distribution to outlets equal, any evidence of solids carryover, any'e.vidence,of . leakage into.or out of bgx,_etc. , a /I. PUMP CHAMBER:. .(Iocate od site plan): Pumps in working order(yes or no): n Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps.and appurtenances, etc.): is P.aee 9 of 1 1 OFFICIAL INSPECTION FOR:M.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR_t1IATION (continued) Property:.Address: Y 7. -A Owner: .. SOIL ABSORPTIONt SYSTEM, (SAS): ✓(locate on site plan,excavation not required) If SAS not located explain why: Type leaching:pits,number: -leaching chambers,number: leachine.galleries, number: leaching trenches,number; length: leaching fields,number. dimensions: overflow cesspool,number: Airiovative/alternative system- Type/name of technology: Comments (note condition ofsoil, signs of hydraulic failure, level ofponding, damp soil, condition ofvegetation, CESSPOOLS: (cesspool must be.pumped a part of mspection)(locate on site plan) Z Number and confiszuration: Depth'=top of liquid to inlet invert: Depth of solids layer: Depth:of scum layer: Dimensions of cesspool: Materials of construction: Indication of:groundwater inflow.(yes or no): . Comments (note condition-of soil; signs of hydraulic failure, level of pondirg, condition of vegetation, etc:): PRIVY:A6(locate on site plan) Materials of constriction: Dimensions: Depth;of solids: Comments (note condition o'soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):. 9 Page 10 of I 1 OFFICIAL INSPECTION-FORM. NOT FOR VOLUNTARY ASSSESSINIENT.S . S;UBS�iRFACE SEWAGE DISPOSAL:SYSTEM !NSPECTION FORIYI PART-.C. SYSTEM.INFORMATION(continued) Property Address: Z17 'G %C) Owner: Date of Ins ection:&Mt C j SKETCH OF SEWAGE.DISPOSAL SYSTEM Provide a sketch of the:sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100.feet.Locate.where public water supply enters the buildingdo A h1-6 El . :oo (4,CP I , Page; 1 l of l 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART.C SYSTEM INFORMATION (continued) Property Address: 1 l' L a /IL.d Owner_: Date of I soection: SITE EXAM Slope Surface water Check`cellar Shallow wells Estimated depth to ground water /� `eet Please:indicate(check):all methods used to determine the high ground water elevation;. . Obtained from system design plans on record-If checked,date of design,plan'reviewed: Observed'-site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators; installers- (attach documentation) Accessed USES database-ekniain: You must describe how you established the high ground water elevation: % / 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: / L �:�'i�t� i G-z`� JC� Lot No. Owner: J ,. j Address: Contractor: _l Address: .ones.:..._..._ STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. :Date month/day/year STEP 2 Using Water Level Range Zone and Index.:Well.Map locate site and determine:. OAppro.prJate index well............... �.. OB Water-level range zone ..................................................... STEP 3 Using monthly report"Current Water Resources Conditions" deterrine current depth to water level for index well ........:......... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) ' determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high water —by,subtracting the water- level adjustment (STEP 4) from measured depth to water j level at site (STEP 1) ` Figure 11--Reproducible computation form. 15 iL L 4 TI, Ai� No... . :.. KA. 1 e �"� / Fss. °7c5............... THE COMMONWEALTH OF MASSACHUSETTS e - BOARD OF HEALTH SUBJECT TO APPROVAL OF .--- mow- ..............oF,,,,,- 8 MSTABLE CONSERVATION c,. ........................... 1 COMMISSION AvOratilan for EliivusFal Works Timitrnrtiun Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal SAem at: .. .. . . . : _.. ... ._... . _ - etc- - '--�- = ........- _ ^Locati -Address f2r Lott .._ C.0 ., &I...�n�o:. --•-t-�CO�--- ._.... 4f���_. !C�::�'S......—Addy ss ................................ .. .�. s .�� ........ S.I.Q Installer Address Type of Building Size Lotg _}�� ....Sq.�feet Dwelling—No. of Bedrooms....... ..................................Expansion Attic (�j �_ Garbage Grinder l ems' Other—Type of Building ............................ No. of persons____________________________ Showers — Cafeteria Other fixtures ___________________________________ _ W Design Flow......,�+�5DY...............gallons per person per day. Total daily ow-..- ` _________._._________.___ Ions. WSeptic Tank—Liquid capacity_ISCQallons Lengthy--6___ Width._�...8... Diameter.---.-_-.... I e 1 .. I x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-_--_1------------- Diameter....NA. ......... Depth below inlet_'.. ._._._. Total leaching area...M�...sq. ft. z Other Distribution box (`t96 Dosin tank (� Percolation Test Results� Performed by-_ �1�����:— Date ti --d- k Test Pit No. I....-/--------...minutes per inch Depth of Test Pit....-�........... Depth to ground water. �lW4,f31?,A� �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...... O Description of Soil........ � _. _ x W U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -----•-•-•----•-----••-----•-----------------------------------------------•-•------._...-------...-•--------------------------•-•------•---------..._•------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Indivic tal Sewage Disp al System in accordance with the provisions of iITLi� 5 of the State Sanitary Code—Theers ne furth Tees no la�ee syste_ m operation until a Certificate of Compliance has b ssued b hh' ealt Signed--- -- -- -- •----- ------------- --- - --• --._...---------------- Date Application Approved By-------- t_•t-e- ... _4 � - ------- ........ Date Application Disapproved for the following reasons:.............................................----•-------•---•-•-•------------...-------•----•---.....---.._._ --•---•------------------------------------------------•-----------•--•-------------•--------------------- -----------•-------•------------•-•--..._•----•---••-•-------•---•---------••-----•-•-------- Date PermitNo........ . ...- ----------- .. Issued....................................................... Date No.__.��`�.._:a l..... FEs....., THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Nil �� � � . Appliratilan for Dhipaii al Works (9=31rurtinn Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Sys at ... _ h...:L. r ........................... ... `I.l_�c.�r:......._...`-� 3 ......- _ _ Locatio -Address r?l�i C i l,1+�+-� �_:t '•!.1, . ...4 ..............`�1..�v, I•+ or \ N��_ ..\��:....................._.... ... ') Owne ._... a k.t�� t �Ve... <�tTr�! 5�2..7--_ tC. Installer Address U Type of Building ��'��� Size Lot_?�_.I.� �r_..Sq. f t Dwelling—No. of Bedrooms___._..:................................Expansion Attic (-4 9D Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures�-•-•---------•-•--------•-••---------------------------------------•-•------••--•-•-----------•-..: �.- W Design Flow......................................______gallons per person per day. Total daily flow................................................_ ..-...... Ions. WSeptic Tank—Liquid capacity-1�Qallons Length_�Q_.`�.. Width... .."(... Diameter................ Depth.. __..o__. 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 (- s Dosing tank (k 1 Percolation Test Results Performed by._.,? '__.-._.Q �C_)I�C_ � .: ........ --_----. --- Date.-- ----_... j -------••-• , Test,Pit No. 1_._.�Z..minutes per inch Depth of Test Pit___A.3........... Depth to ground 7Gr 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil-- 1.G<i�c 1 ____�v Q,So�.t—.__ .-_ ----------h\_ � `--= c. i C"� �� x W --------------------------------------------------------------------------------------•-•-------------------------------------------------------------------------------------------.................. V 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 TITLE: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operatiorr until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... .......................... Date Application Approved By-•--.---- ... . a ` -- -•- Date Application Disapproved for the following reasons:----•--------------------------------------------------•------------------------•---------------------...._._... ...................................•---•---------------------------------------------------------•--------•------------------••- •-------•--------------•---•---••--------••-••------•--•-------...----- Date PermitNo............ .t a`--•....-----.....----•-.. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /� L .......OF.......... 1 ............................. (Irrfifiratr of 19-untplianrr THIS IS TO CERTIFY, That the Individual Sewage DisP)sal System constructed or Repaired ( ) by /� , ...._........ ........f�'e -1..r -L..4�`�"- --! ' Installer has been installed in accordance with the provisi s of TITLE 5 of The State Sanitary Co e- deessc;i edSin the application for Disposal Works Construction Permit No---- _. ,_- _. _.. dated_...____ ----------- f 3 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BJ5 CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAC ORY. /p- � ` 9V . � _ � _ DATE.....--•.••. --------------- Inspecto --- d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No._... �. ........:7 5 _L" ........OF. ,rye ...... FEE... ............ Disposal Workv T11nitrnrtion gymit Permission is hereby granted........... - t- to Construct ( - or Repair ( ) an Individual Sewage Disposal SysStretem atNo..........�• r� -------- �-•------- re:— -t--- .... - 'Dated � s=c as shown on the application for Disposal Works Construction Permit No-�jj ._ �_.. Dated______ . t .- ------------------•---------------•----------------------•-------... .---------•-DATE _ ....... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - 41, No.4 ... F�s...�oo. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH BARNSTABLE C3NSERVAT.CN COMMISSfU�3 i1 ..... ..... .................OF 14, f Sq"P,. (. G.....------......................... Up iration for Dispas al Works Tomitrnrtinn rumit Application is hereby made for a Permit to Construct (�Q or Repair ( ) an Individual Sewage Disposal System At: n ..... ..... _ Location-Addresq, .or Lo o. Owner.................................................. , Addr Installer Address Type of Building Size Lot 2�,_AQ.2------Sq. feet Dwelling—No. of Bedrooms.._3....................................Expansion Attic (o Garbage Grinder ITS Other—Type of Building No. of persons............................ Showers a yP g --------•------•------------ P ( ) — Cafeteria ( ) Otherfixtures -----•------------------------------•-••--------•-----•-•--•------......-----•-••---------.... W Design Flow........ -t' Z--------_gallons per person per day. Total daily flow----- A . ........................gallo s. WSeptic Tank—Liquid capacity.[-_.gallons Length.-I.O.-GI... Width.57:..6-_- Diameter..'..._..... Depth.-..��_:. ... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No....._.._........... Diameter.......l_4....... Depth below inlet.3�S......_. Total leaching area_. 'b...sq. ft. Z Other Distribution box Dosm tank (�.� _ `" Percolation Test Results Performed by. �C �- p p __._...__ Depth to ground water.. Test Pit No. L__4?nT..minutes per inch Depth of Test Pit.... ._ p gr I'.A� _. Lz, Test Pit No.-2..!............minutes per inch Depth of Test Pit.................... Depth to ground water........................ W O Description of Soil.... ._ __3_trQt`4�'!�-•--._ _ l -. -`5- c(17---- .� - M � ----- ----- --�.�_..... ........................----- ---- U = ........ •---------------•---•-------------------••---........................................... W .. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------- •----------------------------------------------------------------- •............................................................................................. Agreem nt: The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed................ .............................................................. ................................ Application Approved By..........=�" ......... ........................ Date Application Disapproved for the following reasons:--••-•-••---••---------•--•---••••--••••••---•--•-••-•------••-------------•---•----.........-•--.........•..... ... ...-•-•..................•••--•-•--------------.....••--•-••-•••• ••-•••...-••--•------•--••••••-------••-•---•-•••---•••-•-•--- Date PermitNo. .. .�—�---------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............��!`?'. .......O F........ 6a n! ..��'....................... Tntifiratr aaf ToutpliFanrr THIS CERTIFY, That the Individual Sewage Disposal System constructed ( for Repaired ( ) by r..........a _.._...��.v2..--•................................ ....................................................................................... l .._� f•1 nstaller — J PI-All �"�'� has been installed in accordance with the provisionsof TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.-... ..............................•-•---•-•---------.........•--•-------•....._.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH FEE.......7 .. Dispostal Workii Tnnstnu$uan ernti� Permission is hereby granted..... _.. c—) . - --•---- •• --------------•----•-••----•-------•-----•--------...------............................ to Construct ( Reppair ( ) an dividual Wage D- osal S stem at No. � sl• 3.1.... `"�- `' Street as shown on the application for Disposal Works Construction Permit No��-2� Dated..._.Z .................... — G ------------------------------------------•• ••--- ------...........---- ........ Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS J Fxs.... �. ' THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH .............................................OF v s L Applirattiun for Disposal Murks Tour rurtion jhrmit ° Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ( ,- t i.l t LCt -- Location-Addressw \.. CSC Owner aUI� C�C_J-lZ -----•-•-......._---•-••-•----•-•--------------• L -i 4 = _,... � E _� L I~Acv!................ ... - 4 Installer Address Type of Building ,, Size Lot..��t..1�_`.0__-_....Sq. feet Dwelling—No. of Bedrooms._...::?...................................Expansion Attic ( D Garbage Grinder (� 5 `4 Other—T e of Building No. of persons............................ Showers a YP g -•--•-•-•-•----•------------ P ( ) — Cafeteria ( ) d Other fixtures . W Design Flow....... -�. :__ .....•...gallons per person per day. Total daily flow..._..'5 _________________ gallo WSeptic Tank—Liquid capacity.I�-�gallons Length___�V=�d__ Width_`?_'._��_._. Diameter---.----------- Depth_g_�"_ . x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------- .-_____-- Diameter........!. ------ Depth below inlet_.3'5...... Total leaching area._ !2_'�..sq. ft. z Other Distribution box Cfas Dosin tank ( �)6� _ Percolation Test Results Performed by._-_--___X.�4__.m ��-__-�_. �._-- w �+ �Z_ d� - ------ Q..c. Date---`-�-�-���---��---�--------� � � Test Pit No. 1_...____---•--._minutes per inch Depth of Test Pit..._g. 7S_....____ Depth to ground water..d�_S? t} _-uUkA�� P ram, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil-- .--'--•- t1 M`�_. .. U E' 1 C --`' �U+ C- �'_F i a 4;� 1' L=,) Y'Vo t x ------. ...................................................... U ---•••--••--•--••-•••---••--••••----------••-•-••-••--------------•-•-------•••-----•--........_.........-----•---•-----•---•---...••---•-••---••----••••----•---------------•-••--••------•-•-------... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------•------•-------------------•--•---•---•----------------•----------....._--•-------•----•••---•--•----------------•---•••--••------•-----•-----•--••---•--•-•--•--•-.......-----•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--------•---------------------- Application Approved By... +'_ _._41, D e Date Application Disapproved for the following reasons:------•-------••--------------------•---•---•---•----------------------------------•-•------••-•...----_..... -•-•-•--....•..--•--•--------------•---------------•-------------•--------------•----------•-••-----...--•-••-••--..._...-••-----••---•--••-----•-•----•-------•----•-••••------•------•••-----•---_..._ - Date PermitNo....---..G: ........... - ................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trr#ifirtttr of ToutpliFanrr THIS4S TO CERTIFY, That the Individual Sewage Disposal System constructed ( .)-.or Repaired ( ) by......................�!�'r�13"? .......<Z��)ZP-.......................... --._..........----------•-•-•---------•----........---..•.....---•----•--••-•-----•--- at--•----------------- _-_��4- ......... Cn- Lam,. --- ..++ .. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated....._-__-.-._._-----_---__-___------_•---_•---. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF..._.... lla ......... No. _ _a FEE. Disposal Works Tonotr iou amit Permission is hereby granted.----i_'._.1__> =;`71..-----•Cxu. ------------------------------••........................................................ to Construct ( t>`Repair ( ) an I dividual ewage Di ,osal stem r . (c � Street as shown on the application for Disposal Works Construction Permit Nok..�._:2�Dated...._` :_.._.....- ...•---•--•----•--•-••--....._ DATE_ _----- Board of Health FORM 1255 HOBBS &WARREN, INC., PUBLISHERS BAXTER & NYE, Mt.- Professional Land Surveyors and Civil Engineers 812 Main Street •Osterville, Massachusetts 02655 Tel. (508) 428-9131 FAX(508) 428-3750 WILLIAM C. NYE, P.L.S.-President PETER SULLIVAN, P.E.-Vice President-Engineering RICHARD A.BAXTER, P.L.S.-Vice President June 23 , 1995 03 �1191 966T g z Nn ¢T,;, . Board of Health 367 Main Street � .._ Hyannis , . MA. , 02601 1' A Re: Lot 31 Beech Leaf Island Road� Map 187 Parcel 63-4 Dear Board : One June 22 , 1995 I conducted a visual inspection of the installed septic system on Lot 31 . Based on that inspection it appears that the system has been installed in substantial compliance with the plan of record . I trust that this letter meets your present needs . Very truly yours , ax r & In f000eter Sullivan , P . E. V. P. Engineering PS:slg �' La 1 P� -P. x ,a 0� y�C S'!i b "1 J ('c �4 I!��i F NA I MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS TOWN OF BARNSTABLE LOCATION LSt A&tc �S E # 1q 1 VILLAGE 0— =t ✓10 IJ;�7 ASSESSOR'S MAP & LOTJJC;=rt 3 6t INSTALLER'S NAME&PHONE NO. t1,Z.�in_rs SEPTIC TANK CAPACITY ! rJO-0 41,&t—. LEACHING FACILITY: (type) ( :: t T— (size) 4 NO.OF BEDROOMS BUILDER OR OWNER /&,Z� �_AW N— PERMITDATE: 6h/` 45 COMPLIANCE DATE: C+f�/J 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) SPIN Feet Furnished by �itLv-�t1 s l 6—r'� i-�rC.CS L AJ s G �-' 33� T ,i . �_ i .� �.' �' All to 7 _, ii _ .. ... r i � -r �_ /` !..� '1� � j��..✓ 'ram `` \ - , c ,i\ Sc:do su ,aE� ,, pav 4AlJ4'/ Sa.. �, .. r� is l.. .. R=c - Pas _ t �11A . PETER' SULLIVAN SUL :Nq.-29733 v, S :FAAAjYl - 3 = meµ. . " u© SI ZII4 FLOW 3 ie.I �S� C.-� ��( ogJ'f �P1 L A w _ ' 5A>CU Yc , 1 klcC -_ B Y 4 x 1—_ -* -- IV �t IN zs y i, Ata41 TdmL J TER .... .� .� •.; + �'� 049.E + su