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HomeMy WebLinkAbout0040 BELDAN LANE - Health 40 Beldan Lane Centerville P A = 189 031014 clll � J�vsc,y.c�o � �, -13 c �oNo.20� HASTINGS, MN Commonwealth of Massachusetts: 18 9`D3�'0/y - Title 5 Official Inspection Form j Subsurface Sewage Disposal System For m_ Not for Voluntary Assessments . r 40 Beldan Lane Property Address Michael Williams { Owner owner's Name information is required for every Centerville MA 02632 page. City/Town 02/24/20 -, State Zip Code Date of Inspection N 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 filling.out forms p �.� on the computer, -5/4 /q eccp use only the tab Mathieu Rebell0 key to move your Name of Inspector cursor-do not N/A use the return Company key. p Y Name 30 Norse Rd —�I Company Address South Dennis MA 02660 City/Town State Zip Code 774-722-0271 SI-14140 Telephone Number License Number B. Certification 1 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. ❑ Faits 02/24/20 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system has a design flow of 10,000 d or reater, the in spector ns ector an d d the system 9p g p ste owner shall submit the report to the appropriate Y P 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. t5in�,doe rev 7fL612016 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. F 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information isequlred or every very Centerville MA 02632 02/24/20 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: ® 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: 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 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. 0 Y ❑ N ® ND (Explain below): t5insp.doc•rev.7/26/2018 Title 6 Official hspectionForm.Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sew age e Disposal 9 System Form- p y Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. Cityrrown State Zip Code Date of Insp ection 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 to a.broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes)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 ❑ NO(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: t5insp.doc•rev.7/26/2018 Title 5 Official trrs petition Form:Subsuftm Sewage Disposal System Page 3 of 18 �L\ Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 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 DEF 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 0 ® 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 cloggedp SAS or cesspool t5insp:doc•rev<`7J28r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary p Y Lary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is Centerville required for every MA 02632 02/24/20 page. Cityrrown 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 distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow 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. El ® 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 15,00Q gpd. For larse 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 li of a public water supply well thin doe.rev.`7/28MIa . - - - . SP� _ _ � TitleSDfridal trisPection Form:S+�bsurfaee SewageDisposalSystem•Page 5 of 18 - Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments /r 40 Beldan Lane Property Address Michael Williams owner owner's Name information is required for every Centerville MA 02632 02/24/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cone.) 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 all 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? 1 ❑ Has the system received normal flown 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: ®1 . ❑ 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)) t5insp:doc•rev.7126/2078. Title 5 official Inspection Forth:Subsuarace,Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is fo every Centerville required for eve MA 02632 02/24120 page. Cityfrown 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): 33.0 Description: 1000 gallon septic tank,d-box, leach pit Number of current residents: 2 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 0 No Seasonaluse? ❑ Yes ® No Water meter readin s, if available last 2 ears usa e d 72 gpd g ( Y 9 (gpd)): Detail: 2019-23,000 gallons 2018-30,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7f2wo18: Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal_System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciaUlndustrial flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NIA Grease trap present? Ye N s ❑ ® o Water treatment unit present? ❑ Yes ® No If yes, discharges to: NIA Industrial waste holding tank present? [1 Yes_❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available* N/A Last date of occupancy/use: NIA Date Other(describe below): NIA 3. Pumping Records: Source of information: pumped january 2020 Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5i6sp.dgc•rev:7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 in 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: 1980 for tank and leach pit, d=box 2020 per BOH Were sewage odors detected when arriving at the.site? ❑ Yes . No 5. Building Sewer(locate on site plan); Depth below grade: feet Material of construction: ❑cast iron Z 40 PVC ❑other(explain): Distance from private water supply well or suction liner town water feet Comments(on condition of joints, venting, evidence of leakage; etc.); Joints tlght,proper venting no evidence of leakage. tsmsp.doc•rev:7MJX18 Title 5 t?ffidaFInsp ection Form:.Subsurface sewage Disposal system•Page 9 of 1a Commonwealth of Massachusetts A ? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page.. City[rown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): t 12" Depth below grader feet Material of construction: ®concrete ❑ metal ❑fiberglass 0 polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon tank Sludge depth: 0-111 Distance from top of sludge to bottom of outlet tee or baffle 33" U.Scum thickness - 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 14" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee's in place in working condition, no signs of leakage or over loading. Liquid level is equal with outlet invert. Tank does not need pumping at this time. t5insp.doc•rev.7/2wma Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldam Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. CrtyRown state Zip Code Date of Insp ection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y ❑other(explain): N/A Dimensions: - N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping' N/A 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.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑'concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/A N/A Dimensions: Capacity: N/A gallons Design Flow` N/A. gallons.per day t5insp:doc•rev:1/26r2018 Title 5 Official lespedon Form:Subsurface Sewage Disposal System•Page 11 of is: Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. City/Town State Zip Code Date of inspection D. System Information (cost.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0,1 Depth of liquid level above outlet invert 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.): box is level and solid with no sign of carryover or leaking in or out of box. 1 inlet.and 1 outlet. t6 nsp:doc a rev.7I262018 Title 5 Official Inspection Fomry SubsurfaceSewage Disposal System.Pa ge 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name informationeicedfor is every Centerville required for eve MA 02632 02/24/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes Q No* Alarms in working order: Q Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A 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: N/A Type: ® leaching pits number. &V ❑ leaching chambers number: ❑' leaching galleries number: ❑' leaching trenches number, length: 0. leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: f5insp:doc•rev. 26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 40 Beldan Lane Property Address Michael Williams owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11 Soil Absorption System(SAS) (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): soil and stone found clean and dry with 2 feet of ponding and 4 feet of storage to invert pipe in pit with no high stain lines or signs of hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes 0 No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): N/A mnsp.doc•rev.7/26J2018 Title 5 Official Inspection Fonre Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner owner's Name information is required for every Centerville MA 02632 02/24/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5in;P loc•rev.7' •1 - /26/20 8 Title 5 taal 1 Offi ns F on omr.Subsurface i Dew D sal S stem Pa 15 of 1 Sewage � Y 8 Jae Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. City/Town 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 1 _ r . _ Q El -O _ ►y, G at ��( � � 3a A Lol. 39 Ay a 8�.l1. 6 � 3 b �� ` Cu - `1I t5insp.doc•rev.7126W16 Title 5 official inspection Form:Subsurface Sewage Disposal po System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is required for every Centerville MA 02632 02/24/20 page. Citylrown State Zip Code Date of Inspection D. System Information.(cont.} 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 25'+feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board,of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) z Accessed USGS database-explain: topo maps You must describe how you established the high ground water elevation.: two maps show groundwater 25'+ Before filing this Inspection Report, please see Report Completeness Checklist on next page. oinsp;doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System*Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 Beldan Lane Property Address Michael Williams Owner Owner's Name information is Centerville required for every MA 02632 02/24/20 page. Cityfrown 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 orattached For 15: Explanation of estimated depth to high groundwater included tsinsp:0oc•rev:A2812018 Title 5 Official Inspection Form:Subswfaos Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS 12 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF.ENVIRONMENTAL=PROTECTION (SAP PARCEL.. ' 0�, � TITLE 5 L0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 40 Beldan Lane_ �,. =D Centerville, MA Owner's Name: Florence Smith Owner's Address: Rrsv� ° '3 2004. Date of Inspection: ,(��•�— ©� TOV4 .4STABLE H- -rt-i DEPT. Name of Inspector:(please print) w j 1 1 i am _ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville„ MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT I certify that 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: i Date: 'V—A—Cj U The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRhw - DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of-the DEP.The original should be sent to the system owner and copies sent to the.buyer,if applicable,and the approving authority. Notes and Comments `*This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/152000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Beldan Lane Centerville, MA Owner. Florence Smith Date of Inspection; g Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. SystePasses: L I have not found an information which indicates that any y 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. ystem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be re laced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. e septic tank is metal and over 20 years old*or the septic tank(whether metal or not is structurally unsound, khibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. "A metal I eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ND expilbservation in: " of sewage backup or break out or high static water level in the distribution box due to-brokcn or obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appro al of Board of Health): broken pipe(t)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obsmxted pipe(s).The system will pass ' spection if(with approval of the Board of Health): broken pipe(s),are replaced . obstruction is R=vod ND ex ain: Page 3 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Beldan Lane Centerville, MA Owner: Florence Smith Date of Inspection: 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 fail g 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 ystem 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. stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 st rface 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 front a p ivate water supply well'• Method used to determine distance ' This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform b cteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: i 3 Page 4 or I1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION(continued) i Property Address: 40 Beldan Lane Centerville, MA Owner: Florence Smith Date of Inspection: — e. . D. STstcm Failure Criteria applicable to all systems: You ust indicate'Ijes".or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool, Discharge or pondingof effluent to the surface`ofthe ground or Surface waters due to an overloaded or clogged" AS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or dogged SAS.or cesspool Liquid depth in cesspool is less ihanW'below invert or.available volume is lessthan%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a.public well. .Any portion of a cesspool or privy is within 56 feet of a private water supply well: Any portion of a cesspool or privy is less than 100 feet but greater than 50 t et from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and (lie 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'correct the failure.° E: Large Systems: be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 pd. You must indicate either"yes"or"no"to each of the following: Ole following criteria apply to large systems in addition to the criteria above) es 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 ou have answered"yes"to any question in Section E the system is considered a significant threat,or answered "y s"in Section D above the large system has failed.The Owner or operator of airy large system considered a Sig ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system owner should contact the appropriate.regional office of the Department. 4 Page S of l l i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Beldan Lane Centerville, MA Owner. Florence Smith s Date of Inspection: e�L� 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.. ZWere any of the system components pumped out in the previous two weeks? J _ 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? i/ _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? c/_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bafnes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Y 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 / c Existing information.For example,a plan at the Board of Health. v — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance. is unacceptable)13 10 CMR 15.302(3)(b)J 5 Page 6 of 1 I F OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C` SYSTEM INFORMATION Property Address: 40 Beldan Lane Centerville, MA Owner: Florence Smith Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):., Number of bedrooms(actual): _ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):,?&-, Number of current residents:9/f� Does residence have a garba gnnder-(yes or no):;'1 d Is laundry on a separate sewage system(yes or no)� [if yes separate inspection required] Laundry system inspected(yes or no):kc� Seasonal use:(yes or no): v. Water meter readings,if available last 2 ears usage d 2 0.0 3' 4'1 0 0 0' g ( y (gP )) Sump pump(yes or no):A!0 20012 — 49,000 Last date of occupancy: COM RCIAIAMUSTRIAL Type of stablishment: Design ow(based on 310 CMR 15.203): Qpd Basis of esign flow(seats/persons/sgft,etc.): Grease p present(yes or no):_ Industri 1 waste holding tank present(yes or no):_ Non- itary waste discharged to the Title S system(yes or no): Water etc readings,,if available: Last d to of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system primped as part of the inspection(yes or no): 0 If yes,volume pumped:_gallons-=How was quantity pumped determined? Reason for pumping: .,...i TYP"F SYSTEM !.-*Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 ]'age 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:40 Beldan Lane Centerville, MA Owner: Florence Smith Date of Inspection:_ L/ BUILDING S WER(locate on site plan) Depth below gr de: Materials of co struction:_cast iron _40 PVC_other(explain): Distance from rivate water,supply well or suction line: Comments(o condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: L Material of construction: t/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) 41 1 , Dimensions: � G Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: _ 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: T r How were dimensions determined: C6,v ye 3 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage etc.): ° d- • d ��`'� �- �'r, i i�•c=L.G'S '-� / !� c Cam°� GREASE T " P:_(locate on site plan) Depth below ade:_ Material of eo tructiow_concrete._metal fiberglass_polyethylene_other (explain): —. Dimensions: Scum thicknes Distance from top of scum to top of outlet tee or baffle: Distance fro bottom of scum to bottom of outlet tee or baffle: Date of last p mping: Comments( pumping reconunendations,inlet and outlet tee or baffle conditio:a,structural integrity,liquid levels as related to utlet invert,evidence of leakage,etc.): 7 Page 8 of l 1 r OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Beldan Lane Centerville. MA Owner: FlQrence Smith Date of Inspection: TIGHT or HO DING TANK: (tank must be pumped at time of inspection)(locate on site.plan) Depth below gra Material of const tion: concrete metal fiberglass____polyethylene other(explain): Dimensions Capacity. gallons Design Flow: gallons/day Alarm present(yes Pr no): Alarm level: Alarm in working order(yes or Ito): Date of last pumpin Comments(conditi n of alarm and float switches,.etc.): DISTRIBUTION BOX:Z(ifprcscnt must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): - O PUMP MBER: (locate on site plan) Pumps in working order(yes or no): Alarms in% orking order(yes or no): Comments note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Beldan Lane Centerville, MA Owner: Florence Smith Date of Inspection: _o SOIL ABSORPTION SYSTEM(SAS): t/(locate on site plan,excavation'not required) If SAS not located explain why: Types . . leaching pits,number: f leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow.cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): I o 6 ra CESSP OLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number a t d configuration: Depth—to of liquid to inlet invert: Depth of so ids layer. Depth of sc layer: Dimensions f cesspool: Materials of c nstruction: Indication of ,oundwater inflow.(yes or no): Comments(no�e condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (ocate on site plan) Materials of cor struction: Dimensions: Depth of solid . Comments(n a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page i0 of 11 OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Beldan Lane Centerville, MA Owner: .Florence Smith Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. g or 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Beldan Lane Centerville, MA Owner. Florence Smith Date:of Inspection: Cr—A—® SITE EXAM Slope Surface water Check cellar - Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 130 feet of SAS) Checked with local Board of Health-explain: necked with local excavators,installers-(attach documentation) `- Accessed USGS database- explain: ' You mus describe how you established the high ground water elevation: I1 No. u Zy _ ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphtation for 11 � aY *pstrm CarYeitruttion Verrait Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) El Complete System ndividual Components Location Address or Lot No.IJlt ' ' �(y �,�j{,,,i/�� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel / 0 j �✓(�; /,`r�1�1•1 /"('G 9�'� / 4�= 4 �— Insst'allller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 4 . /( a) 4 4 , r NIl r I Type of Building: 7 7`t-3 01 Dwelling No.of Bedrooms /�/j Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ��� gpd Design flow provided /44- gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ke D x7 aU cif -k(LI •t A F Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea )Signed Date 2 Application Approved by Date Application Disapproved by 0 Date for the following reasons Permit No. 0 0 Date Issued 1 , r '.biki E Fee t t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicatton for Misposal 6pstem Construction Permit Application for a Permit to Construct( j Repair(grade(, ) Abandon( ) ❑Complete System ®'n1"dividual Components l, h cPlcr�J Location Addressor Lot No.110 ( ( Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /0 9-D 3 1 - 01 5� IV+ �/r i , / <<C.4 Ins`ttaller's Name,Address,and Tel.No. /r.// cc�a / / Designer's Name,Address,and Tel.No. �+C. 5 G► . I!r►C.2� 4,t r N/ivt 1►t Type of Building: �;Y 77+3f-' 7-1 1 Dwelling No.of Bedrooms /�j,( Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria N Other Fixtures / Design Flow(min.required) /�/� gpd Design flow provided /�//� gpd Plan. Date Number of sheets Revision Date t Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Re p&e D-b>,r- e4 one 4,0411 1% Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea h. Signed Date Application Approved by Date Application Disapproved by l l Date for the following reasons Permit No. �U�0 �2 Date Issued "' ? C) ----------------- ------------------- ---------- ----------------- ------------------------------- -- THE COMMONWEALTH OF MASSACHUSETTS �e x BARNSTABLE,MASSACHUSETTS Certificate of Compliance r� THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( , ) Abandoned( )by+ -5A+� 'Cif c, ( ��"TC. ��1�rk.:0, S 1 _ at t f a Le �•� f'mow► /� rcA tQ. has been constructed in accordance } with the provisions of Title 5 and the for Disposal System Construction Permit No.a U�0 -bZ dated fl~ '� 2 c) Installer Z0 1 h Designer #bedrooms /y Approved design flow ( gpd The issuance of this permit shall not be construed as a guarantee that the system Will function as designed. Date ►l 91. j,Z U Inspector �' I'l. ; 0 - --------------------------------------------------------------------------------------------------------------------------------------- f� No. 2 U� "' j Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MispoBal .!&pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at Ud (IR� 4Pl .,tom c-e J-r, Y''t r1 r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. �17Provided:Construction must be completed within three years of the date of this permit. Date 1 /- ` 9y Approved by j t/ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpfication for Misposal *pstem Construction j3ermit Application for a Permit to Construct( ) Repair* Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. v (mloten Ioe C&II(4,41 f e Owner's Name,Address,and Tel.No. /r Assessor's Map/Parcel U 31 C Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 3a` Cikl .X I you-,1► -d ce4•Y,"1 k #,4. Type of Building: `7 7q`3s 3-t^q o 1 Dwelling No.of Bedrooms !V,+ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided NA gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs orAlterations(Answer when applicable) 3,fp j ( .AO� --lA7 aS t rvs�'P6� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea h. Signed Date i Application Approved by Date ,20 :;2—J Application Disapproved by Date for the following reasons azo 9-0 Permit No. 1 ( Date Issued �'— fj ----------------------- ry i�"�. -.,r�.r N-.,. �... ..,.. ., .. .i:,:..r. -•_-, �.-� ..� �k ..+'^.,. ^.-v:-w.� ;.,...�:-.v--=•r _ «J�,f' �a� .+�'"�'�-'.r.:.i t4.t..fh-. d�Nv✓ .� :74f. 1 No. � ^ Oil- + � .• - .. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:.} Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS fiplitation for Disposal *pstrm Construction J)Prmit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. qo fvi y lrtre� �fj✓+}�e. Owner's Name,Address,and Tel.No.1 M( Assessor's Map/Parcel 1 0 31 — 61 LI i t"I — We Install1ler's Name,Address,and Tel.No. rr Designer's Name,Address,and Tel.No. Type of Building: -7 714-3) 3-toy(0 4 Dwelling No.of Bedrooms /v.4- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) } Other Fixtures Design Flow(min.required) gpd Design flow provided /1 , gpd Plan Date Number of sheets Revision Date A Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 'h PRh;/ �Y 01211, 10V .(,gu,k !�Pjd,L 4-4 4 J6r., { � t tk/eS (i�C`-oaf Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heath. Signed Date I fi Ud v Application Approved by Date / 0 "24 Application.Disapproved by Date for the following reasons Permit No. Date Issued G ^ Z 0 t =r - THE,COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS. Certifirate+of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V� Upgraded( ) _. Abandd/oned-(-- )by_ -To by C�4�,�-,-, ��C -"i f-N tJWS at _;P d t,-.v/,r(0 (1pp . e-e41trvi 1-k has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0; CO-I1-dated Installer &1Vt c, Iti�,�� Designer #bedrooms Approved desjgn\`flo gpd The issuance of this p rmit shall not be construed as a guarantee that the system will functio as des[�ned. Date ��p Inspector /` G 5 --------- -. :_--.�. _-. 4=--.:__._ . -- ----- ----"- - - ----- ----- =- - -------- No. ;L C) C) ..-. ( �/ Fee �'S THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal .pstem Construction permit Permission is hereby granted to Construct( ) Repair(V/) Upgrade( ) Abandon( ) System located at 7Q l f kf, /,✓tQ (-p�f>�(►v�IIP Y►�+ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. 7 � n Date "` G �~y Approved by '�L•� s ` s /O ��"1�.Bi...1�... ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH --------.......OF.....,��.//�r ✓`1..6 '....................................... Apptiratinn for Uhipwqal Workii Tonstrnrtinn ramit Application is hereby made for a Permit to Construct (k ) or Repair (: } an Individual Sewage Disposal System at: .......... ....................... .... AV ........ .................................................................................................. �-+ Location,- ddress or Lot No. .......... ir11�"P d2z,_ f��'s�- " ------•--------- /.>�e......._ �L2�. L:%sf ttl-%r. ', :... /� �f `/� Ownery� o r... A dress y j a �-1-v.........�f"!�!!�"f. ... // Installer Address Q Type of Building Size Lot .Y0---------Sq. feet Dwelling—No. of Bedrooms-__--3---------------------------------Expansion Attic ( ) Garbage Grinder (ND) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures .................................. W Design Flow............................................gallons per person er day. Total daily flow......__? .O..........................gallons. WSeptic Tank—Liquid capacity/04m...gallons - Length_--- ........ Width----_r7�------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area._...........a------sq. ft. Seepage Pit No_____________________ Diameter--__-__-----------_. Depth below inlet.................... Total leaching .....sq. ft. Z Other Distribution box Dosing tank ( ), Percolation Test Results Performed by--------- lL�<!��! !!'�C l ................... Date......411-11,-Q-.......... ,aa Test Pit No. 1 L�'rs_R___-minutes per inch Depth of Test Pit_____..... .._.. Depth to ground water.. !� ..____- (i Test Pit No. 2.....Q"`!t...minutes per inch Depth of Test Pit../^Z_..-....... Depth to ground water_-G'� - f --•----------------•----•------ Description of Soil .�.. -- � `" - .;.. U ---------------- rr� .. 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 iIT .. y g g - p y of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has be n issued by eb and of heal i Date oo pp /� Application Approved B -- c�' ! / �� PP PP Y ateg Application Disapproved for the following reasons-....................................-........................................................................... ---•----•-•------------•-----------------••-•------------------------------------------------------------I--•••-•-------•••------•--•--•----••--•--•----••--...----•••--•-----•-•......•-----•---•------- Date Permit No......................................................... Issued_....7- .1 ------ Date V , LPCA � / SEWAGE PERMIT N0. VILLA ��— INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER Pow.// ` DATE PERMIT ISSUED DATE COMPLIANCE ISSUED '��� 61 A"r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /l .................0 F....�� -----------.....................---------- Appliration for Uigpogal orki Tonitrurtion ramit Application is hereby made for a Permit to Construct ,rk' ) or Repair ( ) an Individual Sewage Disposal System at --- •--- Location-Address or Lot No. .af_.:........ z.... ._/.._.....C✓... •---- -----•------••.....:......... r Owner 6 I/ Address w �.l1........... P ----------------"------------................------------..........-•--•--•-•----•••-••-•••....... f Installer Address r' Type of Building Size Lo _............................Sq. feet Dwelling—No. of Bedrooms_____ __________________________________Expansion Attic ( ) Garbage Grinder �J0) Other—Type of Building ............... No. of persons.....__...................._ Showers — Cafeteria Q' Other fixtures ............................ . w Design Flow............................................gallons per person per day. Total daily flow._____-1._2_0...........................gallons. WSeptic Tank—Liquid capacityAAtto----gallons Length--- .__._.... Width---_��........ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.. .......sq. ft. Seepage Pit No-----------_--------- Diameter.................... Depth below inlet.................... Total leaching area.-...... .......sq. ft. Z Other Distribution box ( Dosing tank (. ) ~' Percolation Test Results Performed by--------> �c �'!°.. %►;A�!!�r!�<^ .................... Date.....S � f...�............ ,aa Test Pit No. l�P ........minutes per inch Depth of Test Pit.................... Depth to ground water_f't i�,"_-._____. Test Pit No. 2?!t.!?')....minutes per inch Depth of Test Pit.✓q...... Depth to ground water.14^Yt�tr!�'�r��� r i i O Description of Soil-• ` 'j�� , 4 5 Jd%-- --"--- ........ ................... 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 y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued bye_he board of health. ned .._._._�~ ` XWW -�^-z- a-,e Application Approved BY -_- -- �"'' _�' X ✓' t Dl 0....••-- ,/ "Date Application Disapproved for the following reasons:_............................................................................................................ .-•------•---------------------------•--...-•-----•-----------------------------------------------------------•-------••---•-•--•-••-----•-•---------------------•------•-------•-------------••-•-•--- Date Permit No......................................................... Issued------7-'tl .............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f...U.. '` ...............OF..... r ............ ..%........................................... vErrfifiratr of TotnpliFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed .( ') or Repaired ( ) Z. has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No--- -------- _._ ........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... .` { ..` r .........-••------•-•-----•. Inspector....- A•--•----.-.---"-.•--•-------••---------•----•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ����` �"8 ......................... . .......................................... No.:_:...- .............. FEE.. ?.. ........ Diapos allVorkii Toniatulion amit Permission is hereby granted /. ...../ ................................................................................ r to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No. l- 7' //' . f+,t-.'... �"c''.v�.�/✓ ;I.�. Street as shown on the application for Disposal Works Construction- erwit No..................... Dated.......................................... DATE. ? C� 49......................................... Board of HealTtlt FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS }r rt ti7` ti k t 'F„�:' c�. 17­, tlr' k. t t t T •i tF a{.i b9 '-S'� 4 _1 3 ei > y r t r Yy FFP.4�i/s/lo nn/ L c-/►cy pjT O \ w F.rr`, r �r . - � StU ' � f �` r •pia rt~x SC�gTi/c. V F =xa Vl- 41 m V � 35-100 v , a s; L 6 3 2.3 .Sty S. # j F ROBERT P. L-14-�V BUNIKIS y c p No.2216Z O F'I STE LEGEND v CERTIFIED PLpT PLAN EXISTING .,SPOT=. ELEVATION Ox0 ' EXITING CONTOUR - "_ ._ O FINISHED ' SPOT ELEyAT.JON_. !0.01 �CT / 5Z /3,:f,z �� rt�L�t�✓ F I N 1 S'H E D ,CONTOUR -... p .._ APPROVED - BOARD ' OF -HEALTH _ DATE ` " A GENT SCALE � U1 DATE ` \ 1. &DREDGE ENG/NEER/NG CO. --N- I CLIENT .___ I CERTIFY THAT THE PROPOSED` ' REL REGISTERED) JOB NO.79oG� BUILDING SHOWN ON THIS PLAN„Fa;flEdISTE. ::;CIVIL < LAND CONFORMS TO THE ZONING. LAWS D R. 8 Y ., ENGINEERS, �SURVEY0R-4 — OF BARNSTABLE , MASS. 33 Npt MAIN ST - 712 ,MAIN S.T. CH. BY (� /G F - Y SpF YAFjM.OGiN MASS. HYANNIS, MASS SHEET__ OF DA E REG. LAND SURVEYOR 1 77777-7E4tz;yt `1,47 77qeR 7 IV& W� e_S.FP7'/C rAoVI< OR 20 FT. '1411V. -Aote-1VORdff"�7' -oV,,, Z_,-ACH1.,ovG ,P/r HA A4 07tE.V. peV 0&a.V Ir.*710 -0 MADR.(A IV,EXTRA covc#qerz P/pz 141 =14VY* CAST IRON CC)V-=-)T SH,444- a-= US,_—.0 All". PITCH 11'r FL /Ao' y I Y,h DIRI V.. P V.4 -7- 2;� /W/W A, '4D& CO P'4=,4 CLEAN N10 ..... ..... ..... 2 LAYER 4.,CAS IRON PZ t t- OF M)IV. 017'CoOl GAL. a D1577. 4 WA5HeD 570AIZ SEPTIC TANK •BOX C771V, # Ir .7 • PER7,oW WA5,,Y,=P 5740NE 0 POP PRECA57 AFAS17A6E 0 low hVXERT AT ffU1LD1,VCr FT 6 j-7. P114 r7- VN4,ET SCP7-IC 7,4,oVK VIA M. '041_rLE7_ SEPTIC 7-AV,;< lcr INLET 4P1571?1,5,V;r1otV Box 54,6 ,4-7 GROVAID W,47E1'r 7A,61-E Our4z"rD157-R1,&a-r1-oN Box -54,5,=7 INLET L.eA CH A'Cr Oc"V F7'. AVISR404SA4 SY-S7'&14 TA BU-AT/ON.. ATION.. 7A - LEACH11V6 T 3 A-7-. DRS16N CR I TEM 1A SCALE : Y4 A o lAfZ-N51 0 )VVM8.=R OF BEDROOMS 3 DIMENSION- FT. -tlt,/Al h GReAGE DISPOSAL UNIT 50/Z- Z-.007 I 65.r TOTAL _-S7,6A1A'r.-D - A/ SO/474=S7-#,2 0 GAL. AO�4.Y SOIL -;�ES7 4o'M8EA" OF40ACH11V6 .401*r.5 S-6.z- OA're 0,F' SOIL 7'E.57' ,,WOE 4_-A CH I IVC, jZ2,=_A? .47/7 SO. P7 , RESULTS 1<AVjrV&SS_ jy_ 400 7710M LEACHING So. & IeIVCCAAr/Ov eA70#/10 A-M , -,1,7-07,44 ZeACHIW& AREA _24 6- S4). PT. : FWleC04A7710M RATE A 2_VbSQ. ET. ID14-/V R 0 B E R TTj,. COA42,15 ' IV. 13UNIK C49.1 C', 22162'0 '44 eV S7.qL OYYAW�ViJ: Y,4,OM G stovlv;p� V4 k V,4 C3 GIC 0 VAIZ�_WA 4 AS Z_�ff V.. NAL f "-wo s C 3 ° Z s ' s h .a ' r .. \. ,'" �` ,�• o /OCR 0�4L `Q � � ' � SG-'7�T[r C. d' nn►► • '� A I M t 3s = ds,00. } 13 c 6 65 3,0 i N. ROBERT P. / 1 v BUNIKIS y a No.22162 O �SS ONA =LEG±END CERTIFIED PL T -PLAN r ' EXISTING `SPOT ELEVATION 0,0 Q 1`IAIIISFIIED NG SPO CONTOEREVATI3N T O p � D l_ i� r ,.FMISHED ,CONTOUR -_ 0 - ' IN APPROVED - BOARD OF HEALTH �✓ Ass* .0 All 14 S J .i�l.� b g,iAl `DATE AGENT SCALE � 7D G DATE ,' y LDREDGE ENGINEERING CO lNG'� CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO90 G,9. BUILDING SHOWN ON THIS . PLAN .. CIVIL_-` �" ` LAND ! CONFORMS TO THE ZONING LAWS . ENNEERS�� I SURVEY'ORSSJ DR. BY � �t1.'`�L OF BARNSTABL E, MA S. sil Al _ -GI. � . 33 NO, MAIN ST 712 MAIN 'T. CN. BY /GG RE - SOgYARMOC�N MASS. HYANNIS, MASS SHEET__ OF r2-.. DATE A---- G LAND SURVEYOR ,� e "' •ai'?f"'.r a, x;b *Y-�»rri' � ,w"4.r:'" s #§�9"• v7G c. n 1,. :2m _ ,w"".kdr Y n ti „° •y.-w 'ti� r w�.n 'o` _. ^ti' t • ra ry _'.,-.w :i.�,"f'H'� R..,,•A- wr„ .r ,y: t_I,•. .d„r - _ > s•r '�,,. S 's. - p} .s, •-a 7?q,--R,•7`,g4r SEP TI C TA N M/N. ' k' .QR ' �.;' `•f, r . + " '. .< + SWA L[ B.E B ROUG/NT TO CONGCT E.41/y 61�A OE.Cfl N EXTR/q . CA ST /,VOW COVZFA' SoYALL !3E USE,D �B•PFiQ FT /P,//V OR/VAFWA Y . y z,- 2j6 M/N. CD/VC,QL�TE G1tAGE CC)VER • i— CLEAN SA/V O LEVEL 4"CAST ""�'P/PE 2+LAYER • I M/N. P/TCN ��D Q IRON '• 0 v o /�B - 3�B" %4"PE�t PT GAL. OF D/ST, o. d • • . . . . . . I • ' a oqo WA5HFD S7t�NE .:; SEPT/C TANK c h • • • . . . • I , , ,, BOX O ? 1 1 B 1 • • • • • p Db o. „ .,: ' o v n • I •EFFECTI✓E I ' . 3/4 .', ' , p. • • • DEPTH • • 1 • '• o J�VASHED STaNE °� F: ba• c I • • . ` e • . • I p •bp PRECA5rSEEPAGE !N//eRT ELE✓ATIONS a o I I . • • • • . I I ' e o PIT DR EQL//V. I/VYERT AT BU/LD!/VG INLET SE/�T/C T.}NK 5S,- T R l�! FT. 01AM C SEE 7A _A•T1ON OUTLET SEPTIC TANK 54,9 FT, _ INLET DISTR/BUTTON BOX 54'.6 FT. .+ GROuNo l��ITER TABLE SECT/ON OF OUTLETD/STRIBUT/ON BOX -54.57F7' INLET LEACHING �/T SR,ZF'T. SELVAGE O/SPOSA L SY.�TE/Yf '7ageULAT/DN LEACH//VG P/T DES/GN Cfi/TERlR SCALE : %a " _ /= o--" /�/MEN.S/ON A 3 FT. D/MENS/oN Nl/MBER OF BEDROOMS 3 D/HENS/ON -C FT.7h•//✓' GAReAGED/sPosAL uiv/r SO/L LOG • SOIL. TEST TOTAL EST/M�4TED FLOW n G.4L.1,0Ay SOIL~-tEST �/ SOIL TEST.o 2 !{IUMBER..OF ..EAGN(NGi PITS _ S Z. G Y ! EL EY .,DA TF aF SOIL. T EsT S/OE Z_&ACH/NG PER P/T 1 CS Ly. 1 1. RESULTS N//TNESSED BY G v i< 60TTOM LEgCN/NG PER PIT ? S4 FT <s LO A'� PER COL AT/ON DATE#/ LDSs ly/N'/lNCH TOTAL LEACHING AREA � 6 SQ FT, S.v/3,5014- )CWICCOLAT/ON RATE f*2. T RESERI�EGEACNINGAREA ! $Q. FT. _. �— / 2-0 M/N.�lNCN 4 ROBE- 0.. Cp a E > M '.BUNIKIS `'•" r y"" No 22162 .� EIVG/N6E/P/NG CO,/NG.. r y s 'a '«� �} x�e '�• �fi`! E� �k. s r 'i 4�i .;?.- s �' tw'�g 7I2 MAIN ST,t. s.r: r,»•-� .. ,..., k'ra -,,;33`ND.MAINST. SS' NAL�N6 ^� w"'- NO cr ou D N Yi�,QTE'�t IV OU/NTFR'ED HYANNi3,s•MASS.`} °.SO#`YARMOUTH Q �M�1sS � x ',,> '� • � '�' .IOB NQ:" 910 6SHEET Z OF -. •C.,;, a. � .,it .. . , ... . � i _ r ,. 4 V• r - - _ ,_ .... .