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0156 BEECH LEAF ISLAND ROAD - Health
156 Beech Leaf island Road Centerville P A = 187 063008 /97 _0& 3 -019 Commonwealth of Massachusetts r9 Title 5 Official Inspection Form rC71 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Beach Leaf Island Road ;Q Property Address Laura Groark ` Owner Owner's Name 3 information is Centerville / required for every Y MA 02632 10-11-18 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:When A. Inspector Information C 2 filling out forms P c���# 3 Jam/�D on the computer, '�Q:' JAMES u'_ use only the tab James D,Sears =o key to move your Name of Inspector cursor-do not Ca ewide Enterprises %�'. o use the return key. Company Name 153 Commercial Street '��p�lnNSQ Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); i have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-11-18 I pecior'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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.. Please note: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. t5lnsp.doc-rev.M512018 Title 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 OZ abed xed dH St Z 6 2 602 9 6 100 Commonwealth of Massachusetts ,lo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6. 1) 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: The system is a 100A Gal. Tank D Box and Pit. 2) 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 exfiltrtration 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): 15insp.doc-rev.7/26/2018 Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 16 6Z a5ed XeJ dH St,:Z1, 21.0Z 96 1DO ``' Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5lnsp.doc•rev.7/2612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 3 of 18 ZZ a5ed Y2J dH WEI, 802 86 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 dogged SAS or cesspool t5insp.doc-rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 15 £Z a5ed xe� dH 9b:Z1. 81.0Z 86 P0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v,. 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in illlq=is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped; ❑ ® Any portion of the 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. . 5) 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 CA. 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 t5insp.doc•rev.7,12V2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page s of 1a bZ a5ed xed dH LV Z 6 ME 21, 130 Commonwealth of Massachusetts q ,o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .v,� 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cons.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for aU inspections: 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)] tSinsp.doc rev.7/26/2018 Title 5 Oftal tnspecdan Form:Subsurtsoe Sewage Disposal System•Page 6 of 16 g,Z a5ed xeJ dH LVE1, 8602 86 100 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /; 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 2016-73,000Gais g ( y g (gpd))' 2017-44,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc-rev.706/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 gZ a5ed xed dH 8b:Z 6 8 60E 91• 130 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name Information Is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Daie of Inspection D. System Information (cont.) 2. CommerciaYindustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holdingtank pr esent?. P [I Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurfece Sewage Disposal System•page 8 of 18 LZ a5ed xed dH 817 Z 6 2 ME 9 1c0 c� Commonwealth of Massachusetts 0 Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. city/Tom State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: 1991 - Permit # 91 - 336. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"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.): Pi in is 4"PVC SCH - 40. 15insp.doc•rev.M612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pago gof 18 gZ a5ed aced dH 6t7:2 6 2 60Z 91. 1c0 Commonwealth of Massachusetts Title 5eOfficial Inspection Form Susurface wage DisposalSystem Form -Not for Voluntary Assessments 1k-, 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information Centerville MA 02632 10-11-18 required for every page. City/Tom State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: teat 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 GAL. Precast H 10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" 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 and cover's at 1' below grade. Inlet Tee-outlet baffle. No sign of leakage or over loading. t5insp.doc•rev.7/26/2018 Title 5 Ott dal Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 62 a5ed xed dH 6t7:E 6 SLOE 81, 130 Commonwealth of Massachusetts ,o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is Centerville MA required for every 02632 10-11-18 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 151 nap.doc-rev.7/25/2018 fitle 5 Official nspecllon Form.Subsurface Sewage Disposal System-Page 11 of 18 0£ a5ed xed dH 6U:Z l, 21,02 81, 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name Information is required for every Centerville MA 02632 10-11-18 o page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Note: D Box located under stone wall. Did not open, inspected wlcamera. 15insp.dot-rev.7126IM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 l,E a5ed xed dH 09:Z I. 81.02 21, 1)0 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: *msp.doc-rev.71261'2 0 16 Title 5 Official Inspection Form;Subsurface Sewage Disposal Syslem•Page 13 or 16 Z£ a6ed xed dH 09:Z 6 8 60Z 81, 1)0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Commenis (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. precast pit. Pit and cover at 22" below grade. 30"water in pit wino sign of over loading or solid carry over. 12. 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 Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 1e ££ abed xeJ dH 05Z 1, 8 60Z 91, 100 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is required for every Centerville MA 02632 10-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Dispose System•Page 15 of 18 �� a5ed xed dH 09Z 6 2 02 9 6 1D0 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information Is required for every Centerville MA 02632 10-11-18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14_ 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 t5insp.doc-rev.712512018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page le of 18 5£ a5ed xeJ dH 05Z I• 21,02 91, 100 Sep 12 18,05:06p Capewide Enterprises 508-4774977 p.2 ALf. 30. 2�1E 1:�1; M I Nu. 130� 'r' li I Page 10 of I I OFFIC7A L lNSFIECTION FORM—NOT FOR VOLUNTARY ASSESSHMS SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coruinued) Property Address: 15ti Beech Leaf!gland Roed,Centerville Owner Dote of tagp"on: SKETCH OF SE WA C E DISPOSAL SYSTE M Provide a sketch of the sewage dispo;ai system including ties to at least t"o perm"E t refe=ce landmarks or benchr++arks.Locate all wells within 100(eet•Locate wheeze public water supply enters the building. Beech 1AS•f I3111Ad RDad cs z? Z l 1000 gal tank 1000 gal pit l� '74-Alk' A.,)-Fr 9£ a5ed xed dH 19:Z L 8 U 86 130 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 156 Beach Leaf Island Road Property Address Laura Groark Owner Owner's Name information is Centerville required for evM enery MA 02632 16-11-18 page. ChylTown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nc Estimated depth t high ground water: 13 feet Please indicate all methods e hods 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 8' below grade. Bottom of pit at 5'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t8insp.doc•rev.7/26/2018 Title 5 Official Inspection Form!Subsurface Sewage Oisposal System•Page 17 of 18 LE abed xed. dH 1,9ZI. ME 96 100 Commonwealth of Massachusetts _ Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 156 Beach Leaf Island Road Property Address Laura Groark Owner Owners Name information a Centerville MA 02632 10-11-18 required far every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2,3,or 4 checked ® C. Inspection Summary, 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 0,641 b S r / J3 IT se t5insp.doc-rev.712512D18 Title 5 Official Inspection Form:SuDsudace Sewage Disposal System-Page 18 or 18 SE abed xed dH 1,9Z6 ME 81, PO ZZ®Q COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS u DEPARTMENT OF ENVIRONMENTAL PROTECTION � d C6 MAP PARCEL ' � 3 40 LOT 01'� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS-�— C3 SUBSURFACE SEWAGE DISPOSAL SYSTEM FORIMI� { PART Aco r CERTIFICATION c '" Property Address: 156 Beech Leaf Island Road Centerville MA 02632cz Owner's Name: Marcy Rozanel i Owner's Address: Same Date of Inspection: July 21,2004 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on m 1`ltfltftdlry� training and experience in the proper function and maintenance of on site sewage disposal systems. I am a OF approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: `�•1�•••gsA4q X_ Passes PATR °;m Conditionally Passes = Needs Further Evaluation by the Local Approving Authority s WELT Fails , .� Inspector's Signature: G +° Date: _7/21/04_ ,rnrl+ulti�� 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. Notes and Comments: Observed liquid level in leaching pit 18" below inlet pipe. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ t have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. _ _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fi•om a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma _No_(Yes/No)The system fails. 1 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. Page 5ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous.two weeks ? _X_ _ Has the system received normal flows in the previous two week period? _X_ 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^. _X_ _ 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 _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _X_. _ Existing information. For example,a plan at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of I 1 R VOLUNTARY ASSESSMENTS OFFICIAL INSPECTION FORM—NOT FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ]PART C SYSTEM INFORMATION Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2002—113,000 gal.2003—71,000 gal.=252 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR f 5.203): gpd 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: Tank pumped two years ago. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: _gallons-- Flow was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM —X_Septic tank,distribution box, soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1992 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 BUILDING SEWER: X (locate on site plan) Depth below grade: V Materials of construction:__cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 40' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 6" Material of construction:—X—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: 8.5' long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tees intact and clear. Liquid level at bottom of outlet pipe GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (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.): No hieh stains,one outlet pine. Box located under stone wall not opened checked with camera PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n Page 9 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: One 6x6 pit. 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.): Liquid level 18"below inlet pipe with a high stain 4" above current level CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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..): Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Beech Leaf Island Road g3 (Ai �� L7 Z7 1q 1000 gal tank 1000 gal pit Page I I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 156 Beech Leaf Island Road,Centerville Owner: Marcy Rozanel Date of Inspection: July 21,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked,date of design plan reviewed: _X_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: Location of septic system is 20+' higher than low area abutting property. No.... MAP B tr Fxs....2,5 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH SUBJECT TO APPROVAL OF BARNSTABLE CONSERVATION --J .r..................... ...............OF s `' .............................. COMMISSION Appliration for Disposal Works Touotrurtiun rantit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ... ............................................................... ..1Location-Address or N .......................................' ...............................................� ...�. +�.....: . ........................ Installer Address d Type of Building Size Lot`W.)(Q.> Sq. f t U Dwelling—No. of Bedrooms......Z.................................Expansion Attic 40 Garbage Grinder Other—T e of Building .......... No. of persons............................ Showers — Cafeteria Q' Other fixtures -----------------------------•.... W Design Flow........... ..........gallons per person per day. Total daily fflow......'.19�........................gallons., WSeptic Tank—Liquid'capacity. allons Length b__._6... Width4�.�_.._ Diameter!'_._. Depth.,5.7-8.... x Disposal Trench—No..............:..... Width.................... Total Length...........s.�.. Total leaching area.................... ft. Seepage Pit No._-•--X------------- Diameter....X-A...__..._. Depth� below inlet._ s. __:_._. Total leaching area___---sq. ft. Z Other Distribution box ( �5 Dosing stank (14p _ \� '-' Percolation Test Results Performed by E._�Kk C................... Date._ ..N3 _PB -•I•-- a Test Pit No. 1._4Z_....minutes per inch Depth of Test Pit......tZ_....... Depth to ground water T__6&(WK.° (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' ............. ......... ....._..............------------..:.-----------••- O Description of Soil....0.: _��(? !^ t c�,+4N�c _ I... ----•-------- cxj . ----•-µ=��. ................. '-•-•••••--....••--•-•-•--------•----•----•--•-•-•-•----•••-•--•---•••---•-•-----•---•---•••••.....-••---••. 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 TITILL' 5 of the State Sanitary Code— undersigned further a rees not to place the system in operation until a Certificate of Compliance has be sue y d of h Signed-- l . ...................••... ......--•••-DaYe...4:._ '�i ��,• Application Approved By...... ••• •• . ..... ._ ..;..._... ...-- ......... Application Disapproved for the following reasons:............................................................................................ ... ...•••....... L W"-�l G -7 7 Date Permit No......... s`—��? ------------------ Issued_.--------.......--------------•---•-----. .....------ Date a� 3 tems....�.:_.2............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J Appliration for Dao og al Works Tons#ratrtion Famit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. ..... ------------------ --•---. Owner ddress - W ------�Jc� 1 -------•-------------- tZ� �,�v� .-�......--� ..��• � Installer --- Address Type of Building Size Lot. j......'J --_Sq. feet Dwelling—No. of Bedrooms.___....3................................Expansion Attic (�,l�i Garbage Grinder ( j aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures_.-•---•----•---•-•--•---•--•---•-------•-------•----.....--------•--•-•-- --•----------------•------- -_ W Design Flow...........5 5-1.:� .OA ._ ,.gallons per person per day. Total daily flow........:....a.......__................ Ions. 1... , � WSeptic Tank—Liquid capacity.� allons Length_10_-6_. Width.5�" --. Diameter—7---__ Depth_ _a_-. x Disposal Trench—No. .................... Width.................... Total Length................... Total leaching area....................sq. ft. Seepage Pit No._.............._.. Diameter..................... Depth below inlet--_.-.5...... Total leaching area..._. ..sq. ft. Z Other Distribution box (�tE S Dosing-tank ( t�)U 1 Percolation Test Results Performed by...5 . - '�'.L.................. Date..............._....Z_t._:;._._..... Test Pit No. 1---�i?--•_-minutes per inch Depth of Test Pit......t ?......_ Depth to ground water.N��..�t_VU�TO U,) Lam,, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...___..............__.. ---- p -- t�, l c U 3�U t._ {�tom` (1e 1�1�\)1.�1�, _ _ -_ _ Description of Soil - . ........... �•--• ...........................-. -J ----....---- 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 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 by4thdard of healthSigned !%. .r'�__'_'_. i�Y = = ,. � -. �DateAPPlication Approved By------ � ._ Dated _T Application Disapproved for the following reasons:---------•----•---------•----------------•------....------•------••-•----------•----•-••......•--.............. --...-•------- {`.---•-----•-------------------------------••------ ...-•------- ••-------........-------------------•-----------------•-----------•-------------------...------•-----. d f `J 1 Date Permit No..------.. ------------ Issued-------------------------------------------------------- ----------- -- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (Inr#tfiratr of Tontpliattrr THIS IS TO4 CERTIFY, That the Individual,sewage Dis osal Sys em constructed ( 'or Repaired ( ) by................. .�-r_¢. ......---- t_,_. _... J_ � 1 ��C� ....-•----•----------•----------...-•---•------------•--•--------••-- at------ .•- =------------- -�.gr L L n . ��G..+_<. C::='-= ''Y Install �y ............ - has been installed in accordance with the provislolls of TITLE 5 of The State Sanitary CCo�e as de-cribed in the application for Disposal Works Construction Permit No........... .... dated_-..._---- ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT Bi*ONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION`_SATISFACTORY. DATE.............................1�.= ?.�.....------------•...---- Inspector...------...... . . ...................................................... lam / THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (2, r. ................ :vt .........OF......... e �:- .............................. FEE.... FEE.... ........... �i��o�aa1 ork� �ono�rnr#Uan �ernti� Permission is hereby granted.......... _ . %�J��� {.,_.............................. to Construct (�or Repair ( ) an Individual Sewage Disposal System � at No.•--••-......---- G...c .......:�,.�,, -�.�/.)�. [� �� /p. // ?�E Dated---... . 3 9 .............. Street as shown on the application for Disposal Works Construction Permit No. ._ f ' Board of Health V DATE---....... ........................... ..................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS +fie ! �•�;g, Vol, oI�T................-....... _............... THE-COMMONWEALTH O MASSACHUSETTS V BOARD,-.,OF HEALTH SUBJECT TO APP. — BARNSTABLE CONSERVAT1011 1.�. ►,A..._.... .OF .... .►.1� :T ---•------------•----------------- COMMISSION Applirution gar Disposal Works Toustrurtion "truth Application is hereby made for a ermit to Construct (K or Repair ( ) an Individual Sewage Disposal System at: .............. .................... ------•---•-----•-----•---•-•-•---•...--•--•----_---- --•- - _ _ Location-Addres _ C EGA tL f ..�� >�C.. .--•-•--•----- J- �� AA� T�o Lot No •---- ` = .....- ...... - _ Owner `, ( ress - '� 1.__._ t�C ............. ......... � °tiT �.... Ekeu(1L_ �-11 Installer Address Type of Building Size Lot_!Cj_-!�3Z__._Sq. f et Dwelling—No. of Bedrooms_ ______________________________ ______Expansio ttic ( p Garbage Grinders-S 04 Other—Type of Building ............................ No. o erson ___________________________ Showers ( ) — Cafeteria ( ) Ga Other fixtures ..................................................... W Design Flow_______` _.7 tf ..........gallons per perso er y. Total d�il flow----- ......................gallon. WSeptic Tank—Liquid capacity_1gallons Len IU'�____ Widths _ _.._ Diameter________________ Depth_ _^ ... x Disposal Trench—No. .................... Width_________ _________ Total Leng -------------------- Total leaching area....................sq. ft. Seepage Pit No........I........... Diameter......I ......... Depth below inle 3A�___..... Total leaching area_3. ....sq. ft. Z Other Distribution box N45 osin�,tank a Percolation Test Results Pe rmed by..']2 X ._. ............... Date___.L`._.VA.:�I ...... Test Pit No. 1__/-_'Z..... mutes per inch Depth of Test Pit... _. Depth to ground water__,f-iq TG"X40 fs, Test Pit No. 2....... ......minutes per inch Depth of Test Pit..... ......... Depth to ground water..... .!_____________ t ........................................... O Description of S Gi_-Y_ '_..-- --- �-6A--'(U � �xrLV- C�. I�A U - - ---•- _.:_ - UNat e 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 operation until a Certificate of Compliance has been issued by the board of health. Si=ned..................... ••-.......................................................... Date •-•-•-•- _ Application Approved By-- - _•----------------------• -••-•----------•...-••-- ) :--- Date Application Disapproved for,the following reasons:.............................................................................................................. --•................•-•-•---•--•-•......•--•-•••-...._.._•--••--•--•-•••••------•••----......-•---_..._._..--••--•-----•--._..----•-•-•••••---••-•--••--••-•-••--••-•-•-•-•-•---•-----••••--•---••-------- q Date PermitNo....... .............. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..:.......................................OF fitrrti�irtt�r laf �uut�rli�anrr , THIS<tj:�O by.......................... IT IFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ••---•••-._........ ,-------------------------------------------------------------------------------------------------------------------------------------- Installer has been installed in accordance with the provisions of TITLE of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... __: _._ dated_..._7�. A-- 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 _ .............OF._:.:..... - ._C7._......... No.. FEE. Dispogal Works Tonstrudiou rrutit Permission Is hereby granted ` '�. ------ -------------------------------•- to Construct ( or Repair an Indi idual Sew-agerPisposal System ( Camsl. Street as shown on the application for Disposal Works Construction Permit N __ D ..____------ ......................... -------------- -- -- "�---_ DATE................................................................................ Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - _, No................--....... Fps...:........................ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ....................OF 6AZ.�S L_E-'. Appliration for Dispaii al Works Tutuitrartioat thrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at* 3 r 1a� ���t lLb —fJ-T- -� ................_....._.._ •-......_........... ... ................................... ......-----•................. ....._.... Location-Addresg or-Lot Uo C Lit t Lk J 11' _ S LMv�, �,, c' Ec1 �"L i�.;` J 1 1 (.�............... t i ........................... .... ...............---•- ... ......••••..._...... --•---•--•--....._.......`t-•-....... a Ksj E 12t Owner -Addr/ ,zciA.T\0 .............................. ..................................................... ••....._ ................•••..-- �?..e..s.s.i`C r+ ....t L ...... Installer Address Type of Building Size Lot............. ...Sq. f t Dwelling—No. of Bedrooms..`..............•...........................Expansion Attic Garbage Grinder Other—T e of Building No. of persons....................•._.____ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Q Other fixtures — -- ---- ------------ W Design Flow.......`�✓.:?--?� ..........gallons per person Rer day. Total daily flow___-. ��........... ............gallons�� WSeptic Tank—Liquid*capac>ty..�.: -gallons Length_�C _......._ Width...:. -'.___. Diameter---------------- Depth.-_---- _-. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area---- Sq. ft. . Seepage Pit No...._..._1....._.__.. Diameter.__...., __..__. Depth below inlet...0:.:�__._._. Total leaching area... "_�__.._____sq. ft. Z Other Distribution box (�YT5 Dosing tank Percolation Test Results Performed by._-1=.� 1Z j.. �±'.�= "-t �- 1 < ` T_ .. Date---- '--=--..--...� ......--- Test Pit No. 1.../.. .....minutes per inch Depth of Test Pit...3_........... Depth to ground wate....`l: .......L.... (s, Test Pit No. 2---' ......minutes per inch Depth of Test Pit..... Q......... Depth to ground water.....`_............... R+ •------------------------ ------------.:.......---......------. -•-------.... --• ......................................................... 0 Descrt t* of oil....... = '�.... t-.�_.`' `� J x 'r�4 �' �'a - ���!__� �r C-t,'r `s t:;. ............................................ W 2 ! u��r�s -•�! r\,vti^t( t2� UL,t , (j 3 !! �: Aik t�7 --------------------------------- ---•-----------• ----------••-------- ------------:--•-•••••--------••-----•------•----••-•-•-------••-•--•---•--•--•-••-•--- 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 TITHE 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. Si. ned---....-•---�•---�-. r ....................................................... --••••--•---•-•-••- , Application Approved-BY to C .....•-------•--------------• . _— ------- Date Application Disapproved for the following reasons-----------------------------•-----------------------------------------------•--•-------------••--•••--.......••- .......--•----•-•---••------•----•-----------------•---------•------------------------......--------.......----•---...•....----------------------•----------------------------------------------....••--- _. i.. . Date Permit No....... �� c _ ..._ ••--•-.._.. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................I...I.................................I....... Trrtifiratr of TautpliFattrr THIS dS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( ) .� ------------ _ r Installer has been installed in accordance with the provisions of TITLE 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 No& �.� .............!�?tiv ...........OF..........''--.::..:�._.�t� =...s. ��;'�- _ _.. .i �( FEE 1.. .... �i��r�ao�l. or�,� �oato#rttr#ion �eroti# Permission is hereby granted---...... :.._....`5'�.V��..... to Construct ( ) or Repair ( ) ,an Indiv`i_dual Sewage Pisposal System \ at No !. .. . ti "-?C{i/} .4_c'r`" ss ..................................................................... r Street _ �-_• •-••.•-• as shown on the application for Disposal Works Construction Permit NO5 -?: t Date ?_ l^-:l�E. 1 --- -•-----•--•-------...............••--- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. 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