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HomeMy WebLinkAbout0074 BRIDGET'S PATH - Health 74 BRIDGETS PATH 1 CENTERVILLE A = 170 239 No. 42101/3 ORA do, Ed E alz 10% o ® o a .... r a a39 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments } . a � 9 P Y rY 74 BRIDGET PATHS } Property Address h'O t'j CLIFF PONTE ' Owner Owner's Name information is ✓ { ; ` required for every CENTERVILLE MA. 02632 12-10-18 page. City/Town State Zip Code Date of Inspection 1= r; ja.. 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 filling out forms A. Inspector Information 13D5 on the computer, TOM SILVIA use only the tab key to move your Name of Inspector cursor-do not use the return Company Name key. 377 WILBUre AVE. Company � Company Address SWANSEA MA 02777 City/Town State Zip Code 508-965-5758 S13001 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 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 12-17-18 I spector'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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 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: THIS ISSUANCE OF THIS INSPECTION FORM IS NOT A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED 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. ❑ Y ❑ N ElND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 page. Cityrrown 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): i 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. x ` 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 Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i , r , Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is CENTERVILLE MA. 02632 12-10-18 required for every page. CitylTown 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: • r , 4) System Failure Criteria Applicable'to All Systems: w You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ : ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 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 the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® 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. 0 ® 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 ,stems large s you must indicate either"yes" or"no"to each of the following, g y y y g, in addition to the questions in Section CA. Yes , No r ❑ ❑ 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 Il of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 coil Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 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? ❑ E 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 74 BRIDGET PATHS �L Vx Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 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: NSA 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): TOWN WATER Detail: 2018 196,000 G (536 GPD) 2017 77,000G (210 GPD)2016 150,000 G (410 GPD) Sump pump? ❑ Yes ® No Last date of occu anc : N/A p y Date i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts i= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? El 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 page. Citylrown 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): OVER FLOW BEE HIVE Approximate age of all components, date installed (if known)and source of information: BEE HIVE 1979 NEW FIELD INSTALLED 2001 ALMOST NEVER USED Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5feet 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.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ' 1000 Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness c CLEARISH/ 1 INCH 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? TAPE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I highly recommend pumping every 2 years. The Inlet and Outlet t baffles are in good condition. I highly recommend A FILTER BE INSTALLED & maintain the filter in the outlet t. The septic tank is structurally sound and there is no evidence of any leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 , s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name. information is CENTERVILLE MA. 02632 12-10-18 required for every 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: F ❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): Dimensions: R . 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, r ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: : gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 it page. Cityrrown 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 NO Comments (note if box is level and.' nd distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts +n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is CENTERVILLE MA. 02632 12-10-18 required for every page. CityrFown 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: THE ORIGNIAL BEE HIVE ONLY WORKS 75% OF THE TIME. THE NEW FIELD RUNS AS A BACK UP TO THE BEE HIVE. THE NEW FIELD IS IN LIKE NEW CONDITION AND CAN HANDLE ALL OF THE DAILY FLOW AND ONLY TAKES 25% OR AS NEEDED. THE WAY THIS SYSTEM IS SET UP, IT SHOULD FUNCTION PROPERLY FOR MANY YEARS TO COME. Type ® leaching pits ' number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑' Teaching trenches number, length: ® leaching fields' number, dimensions: 1 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form `a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is CENTERVILLE MA. 02632 12-10-18 required for every page. City(rown 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.): THE ORIGNIAL BEE HIVE ONLY WORKS 75% OF THE TIME. THE NEW FIELD RUNS AS A- BACK UP TO THE BEE HIVE. THE NEW FIELD IS IN LIKE NEW CONDITION AND CAN HANDLE ALL OF THE DAILY FLOW AND ONLY TAKES 25% OR AS NEEDED. THE WAY THIS SYSTEM IS SET UP, IT SHOULD FUNCTION PROPERLY FOR MANY YEARS TO COME. 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 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF POINTE Owner Owner's Name information is CENTERVILLE MA. 02632 12-10-18 required for every 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 Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I- IA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is CENTERVILLE MA. 02632 12-10-18 required for every page. CityrTown 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-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is required for every CENTERVILLE MA. 02632 12-10-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells .Estimated depth to high round water: 10.5 p g g 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: 1979 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: AS BUILT ON FILE AT THE BOARD OF HEALTH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts im Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments « / 74 BRIDGET PATHS Property Address CLIFF PONTE Owner Owner's Name information is CENTERVILLE MA. 02632 12-10-18 required for every page. Cityrrown 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 t5insp.doc-rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i B t w > a r' �;_� � iaa�6ot � IXv34e.f.Lt` t t 0 - _ 2.57 7.FOM u avotrr�- f /854e �.— n�7{G.�y �33 - � a VNkB.aG,ff 4t' }x ifo s,vc/s a.Ja•+x * 330 4A4,/cwr _- a ?1/l.'Ax liccPav9� ir G'YAc.r .*mow poi r�lr� SrIT�/yi >• . . ,.,. ,a .-` S:t+dw.v,Gc.s fBs S.<, h 1.3 6,Ot/CLI y�J.6 470 Gip[,./ply/y' rt jN ma�yy,, gHU 5ti.ir/^IbPI crry t+ %i, );ACl3:rry: (type) L .�.° t ER OR 0W- M P, Zoo - ^ -_ •. � � _ Wiz§. � TOAT Lion ()jst c.,c Sletwun the b., Ility Ot;�atl dUd 4 j fuwty Wifty wetl ds exist Y � _. e''a •f.+'yMw'� - s';#•,� *...} y 4 �� ;*#t",' '1. � `a ''°�„°�"'�� g�*-��py- 4 ;+( �'"t4' � "�i."�' ��c�°. sp _ S r 'Xi �4 4 0 1.c .01 -13 k l TOWN OF BARNSTABLE � � h Va,LAGE 'O� A ASSESSOR'S MAP &LOT 17U—Z3 INSTALLER'S NAME&PHONE NO. /"` � L ea,� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C-T ) 1 ►dT Ar *e) •� — 5� NO. OF BEDROOMS 1_ BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r .. _ 5 , 16 �' 0 2 C o No. ?�� ��L/� :� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 01ppYication for 30i5pogat Opgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7qlJr t �JS f l2 Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0 D �� / (� T Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size t�Lf sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title vO U T t Size of Septic Tank � --Type of S.A.S. 7 7_4 � i i Description of Soil; O f�l a r "�-'z t�U Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued by 's Bo of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons i Permit No. Date Issued Fee ' No.- W v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS �- 01pprication for Migponl *pgtem Congtruction VernttC Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 794 Or fI S yQ ti[`� Owner's Name,Address and Tel.No. Assessor's Map/Parcel f '1 D l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. nx LK '� 4r Type of Building: Dwelling No.of Bedrooms _ Lot Size` t sq.ft. Garbage Grinder( ) Other Type of Building . No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f 4--'C7 U Type of S.A.S. q t VC ( tom. `f S'F�I1C tLl i fir . Description of Soil /D O l 4P Y l l a r Gam-¢ Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued by t is Bo of Health. Signed Date �+ Application Approved byZAZC,�t, Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS ARQST-•ABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by /tx L 2 L-e_-Cc Y, at '7 k( &rid oe ff- c Ath has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.701 - / dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the s, m will functi n as esigne, . Date HV Inspecto�'� �.^uu_., �� - 1� ———————— ——— - —---———.——.———————————— No. V17 Fees \ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal *pgtem Congtruction 3permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Aba don( ) System located at .7 �►'�mac, f !/�4� �-A and as described in the above Application for Disposal System Construction Permit.The applicant recognizes 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 t. Date: G/Z /y� Approved by �-�_ I 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM cL i^c , hereby certify that the engineered plan signed by me dated Zz- a , concerning the property located at Lf rr t .-Pq b- t :�- C 1 1E ,� t meets all of the following criteria: This failed system is.connected to a residential dwelling only.. There are no commercial or business uses associated with the dwelling. • The-soil is classified as CLASS I and the percolation rate is less than p or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the.site without a health agent present. �✓ There is no Increase in flow and/or change In use proposed � There are no variances requested or needed. � The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Fnmptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) C B) G.W. Elevation + adjustment for high G.W. DIFFERENCE BETWEEN A and B SIGNED,: DATE: NOTICE - Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health_folder:percexmp lee ti5i4fv5"!J" k� - `7 ;= f k 2 rt a 3 n,y� iy •4 Y .�''r xe r .i�s. .v i. iq,ty'a` - .;. k ? x: rr ��.i,.�� '�•--'Yc "krr3`+ �r �sTMv TOWN OF&A STOLE :LOCATUON t .. SEVYAAGIi Ztf V41, // .. VILLAGE "�(L ASSESSOR'S MAP,& LOT /70-2-3 .INSTALLER'S NAME'&PHONE NO. 1`l-"e. L ea- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO. OF BEDROOMS BLUDER OR OWNER < � .`�� 1 Y�C PERMITDATE ZS" J. / COMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom ofLeaching Facilify Feet Private Water-.Supply.)Nell and Leaching Facility .(If any wells:ezist q ' ' on-site.or wtt#un 200#eet of_leaching facility). {;. Feet Edge of Wetland`and Leaching Facility (If'any wetlands exist within:aOO feet of leaching facility) ti Feet FLimsfied by 2 l� - ---_- _ o ' l f TOWN OF BARNSTABLE ,LOCATION L � �pCol'r'S ��I' SE GE # -a VILLAGE ASSESSOR'S MAP & OT ��OB INSTALLER'S NAME &PHONE NO. E?,,�;y -s- te-A 396-17P O SEPTIC TANK CAPACITY /0 00 LEACHING FACILITY:(type) vP -1490 a Co AR S (size)�670 .� NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER y-a,,,,.,_ DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: `'7 1 S F 7 VARIANCE GRANTED: Yes No ✓' - t2 aA t9 G /vax r��p ASSESSORS MAP NO: Q —7 PARCEL NO: No...-D_...-.- . d t� Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Q ...............OF.. ................................................................... Applira#ion for Bi-oposal Works (fututrurtion tirrutit Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal System at: Location-Add"' [ or Lot No__._______. . ner Ad ess Installer Add, Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------------ Expansion Attic ( ) Garbage Grinder ( ) -----.--- '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___..--_.--•_-.--_--sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------................. fi Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water-...•-__--__.._----_--_- P4 -•------••--------------•---•--•--•••--.....••••••••-•--•--•--•.....---••-•----..........------•-•-'......................................................... 0 Description of Soil......................... x -------------------------------------------------------------------------------------------------------------- .---------------------•-------------------' ............................. U N tu�lre of Repairs�o(r� Alterati�uE q/ Answer whe�n)a licableL_/�f/ 1 /�/ _.-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITli: p 5 of the State Sanitary Code T'- undersigned further agre of to ce th/sys min operation until a Certificate of Compliance has be s e oar f h. Signe .•--- ... . --- � J--A lication A roved B -_-..•__-_._-_.-•-_ �.- -__ PPPP Y -• --- •...••• -----------•-- ...-•--••... .... Date Application Disapproved for the following ons:-••••-••----•-••-•-----••--...-••--•--••-•---•-•-•--••-•-••--•--------•----••••••---•--••--••------------------- ----------------------------------•-----.........-----------•--------------•-----.......------.......---•--••-••-•-••----•----------------------•----------------------- ------------------------------- g� Date PermitNo....Lli _`._. ..----------'-----._...-. Issued-....................................................... Date No....fit.......... .. ° —! Fps.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.Ot c, ................oF. cz.................. ......•-----••---------•------........--- Appliration for Diopnsal Works Towitrnriion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ....... .... ......... ....................------••....------------•------•-------._......_.....--------........ �. Location-Addre` ! -... Lot No.......................................... .... .5.......... ........:.r..��s !1 Adi}ress installer Add ss Type of Building __7 Size Lot____-----•----_-----------Sq. feet U Dwelling—No. of Bedrooms................:7_.....................Expansion Attic ( ) Garbage Grinder ( ) ............... No. of ersons....................._______ Showers — Cafeteria Other—Type of Building ..._._......• p ( ) ( ) Q' Other fixtures ................................. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity------------gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_______-._•-_--•----sq. ft. Seepage Pit No------------------ Diameter.............------- Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water______.______-•-•--____. rZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix ---•.....••--•.............................................................................................................................................. 0 Description of Soil----••••••-•-•••-••••••••-••••••••••••••...••••••-••••...--•••-••••••••••••••...•-•••------••------••-•-•---•-------••••••••••••••••-•-•................................ x V -••••-•................••--••-•-••••-.._..........._........_..................._........._____.........._......_...._....•••-••..._.----._.--••••-•••-•-•-__._......-••••...•--......_......_.__----••. W x U T ture of Repairs or Alterat —Answer when applicable--/QQ -!!�----E�_ 'P.-.14 .i4t?i-a-!.Q..../.-1000... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys ai m ccordance with the provisions of T ;of the State Sanitary Code. T' undersigned further agre s not to *1ce th/sy em in operation until a Certificate of Compliance has be n'i e oar of h. r Si . ..... _-••• ... ---A lication A roved B ^``_ ••• _........a r�::.:..................•••-••................ --•••-•••• _.. Date Application Disapproved for the following axons:......................................... ---•••••••---••---•...............•....._......._. ----•--------- ...............................•--._......-•-•-•••••----.....__._.........------•.__._._._............._......__...__...._........_.__....._..._..._•-----------•--•-------------------•................ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ...0. ....................OF.........................E�!....../�'.��..................._.... (VE rtifiratr of Tontpliattre THiS is TO C F 1, hat Individual- ewa is osa tem constructed ( ) or Repaired ( } byT ---... ....-... .................................................................... 11 Installer .--- at...A_.J •............... . - ?h -. .__!........................................................... has been installed in accordance with the provisions of T T rrj j1of� State Sanitary C de as described ' e - application for Disposal Works Construction Per...., No..�......�:.. .......... dated----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... _.�..� .. .. . Inspector.......... --------•---------.--•------ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH r .........:.......OF..........:....... ...................... ... N �V o. ..................... FEE Disprsttl rko Tan ion rV..CPermission is herebygranted_.....___. Z?_C �i ...._..-. � A_. •__ .-----•---•------------------------------------- - to Constr ct_.( orf��girj ) n Individual ew e•Disposal System �t PTO..... ....... ....... _C �..+�. .1.............._ �_... .....I......__...•...�.....� � .................. .._.._.......± .. / -- --- ------•- Jtreet `�}t as shown on the application for4sposa1 Works Construction'Permit No?__......�.?._..:__ D ted.......................................... r. � r3"o2' Health FORMDATE..........- •�•........................... Boa FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LOCATION a SEWAG PER IT�No VILLAGE INSTALLER'S NAME i ADDRESS IM-rof« a ga d AMAEA--,17-A BUILDER OR ` OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED Py-3d --� go v o �I (\ FEB............... No................ ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .............Town.................oF....`...Bar�st_able.---.---------........•--.................. . ppliratiun for Di-sposal Vorhi Tomitrurtiuu rjormit Application is hereby made for a Permit to/;Construct ( X) or Repair ( ) an Individual Sewage Disposal Systemat A 171.........................I......... ------------------ -- ---•-•-------------•-••--•--_-••-•-------- Lot 25 .. _...__ Location-Address or t r!t ------ Bri dget s ai Owner ; Address ................................i 0.. 20 r 1F_�• ........:..............•-•- 2N T t��F.....•------------------•----........_._.._ -- - Installer Address 15 ,000 5 '000 d Type of Building ` Size Lot____________________________Sq. feet Dwelling—No. of Bedrooms________________3_.________.___________-__Expansion Attic ( ) Garbage Grinder (no) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Q' Other fixtures ........................................ W Design Flow______________-_5-------------------------gallons per person per day. Total daily flow...................3.3.0.................gallons. WSeptic Tank—Liquid capacity]-000_gallons Lengths !L...... Width.]+!.1Q f 1 Diameter________________ Depth_4,1 0 rr x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area---------_..........sq. ft. Seepage Pit No---------1---------- Diameter.....10-......... Depth below inlet.......6_t......... Total leaching area.....2.67.....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) Percolation Test Results Performed byCape---C-O-d...Survey.__OIInaliltantwate._1/5_/7.9____________________- Test Pit No. I........2......minutes per inch Depth of Test Pit-----10...5_T__ Depth to ground water---.7.0.._5_T.___._. Test Pit No. 2........2.....minutes per inch Depth of Test Pit.....12T....... Depth to ground water----n.Qxle......... •---------------------------------•---•-....---.._..-----------......_._....._.................•----......................................................... O Description of Soil_#,-......0._0-2_.Q---w-oo L__1Qam._&__.suhao 1_r_-_2_•_0-T4-.-5__- nd, x U ---•------------ __sand.------#2......0._0=2_..D__vroad---ls.am--&--,alab.so11............... ----------------2-.-0--5_.0---med._:_ysllaw----samd_ 5_0-O 6_._Q---loam--- fine...yel).ow U Nature of Repairs or Alterations—Answer when applicable.___S_3ZL ,____9._Q-__.12__Q__-flne---Wh7. P�fH�3f'�Llgs ' Agreement: =ya`� dq�, The undersigned agrees to install the aforedescribed Individual Sewage Disposal System OPZd MKWV >tiN the provisions of TIT .E 5 of the State Sanitary Code— The undersigned further agrees not to the system i operation until a Certificate of Compliance has been issued by the board of health. CHAPMAN cn A A No. 27654 Signed..................................................................................... � �Q�s— ��a`��` Application Approved By....................................... FS NAL ENG\ ------------ - ---- e Application Disapproved for the following reasons---------------•--------------------------------------------------------------------------------------.........._ ..--------•------.-•..----•-•------------•--------••------------------•-------•-------=----•----------•---•----•--•-•---•--•-•-----------------------------------------------------------------------•- j Date PermitNo......................................................... Issued_----- ........................... Date No...._..... / ... F�$....�`....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEALTH ............-Tam... ............OF...4..Bs �:�xAt3 fr' Appliration for Disposal Works Tonitrurtion Viermit Application is hereby made for a Permit to onstruct (g) or Repair ( ) an Individual Sewage Disposal System at: . ......_ r ..�. ca ........ LOt.._2 _... . ..__. -......o ....._._.._ .... Location-Address or t 'r.! -•------------------Grid ...... ...._a Owner Address a ••••..ET 2._ c 24T l Q ..:......................... ( tU ST t . ......................................... Installer Address 15 ,000 Type of Building- Size Lot............................Sq. feet aDwelling—No. of Bedrooms................3 ...........Expansion Attic ( ) Garbage Grinder (no) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a ... --- ------------------------------------------------------------------------------------------------- � Other fixtures .............•-----. ._. ...---•------•----•---- � Septic Tank—Li uid''ca acit QQQ.gallons per L Length .6f1..__ Width. '1Q". Diameter._... 3p-- D gallons. Desi n Flow...................... gallons person per day. Total dailyflow----.-------------- P q P Y1 jt-.. Depth-1�.t Q rr---- W Disposal Trench—No..................... Width._...__...__._..._.. Total Length.................... Total leaching area....................sq. ft. x . Seepage Pit No.__.____1.......... Diameter-----1i)_i.__-_._- Depth below inlet......6 T_...._... Total leaching area....26 -----sq. ft. Z Other Distribution box (c Dosing tank ( ) aPercolation Test Results Performed byCape.-Catk--.Surrey__-GansXLLtantdDate..1/5179..................... ,--a Test Pit No. I.......2......minutes per inch Depth of Test Pit.... Depth to ground water....1.0...$......... (i, Test Pit No. 2........2.....minutes per inch Depth of Test Pit.....121....... Depth to ground water---none......... �+ .............................................-............................................................................................................... O Description of Soil.#1.....JQL.0-2,-4..w orl---10=--&-.suba0i1.,....2.O.-4...5..meLc..•..zaax.s.e-..sand,. ------•---- ��-5�1�1. m� _... rP-11 Ow--.aa?a. #2 0-•" -2A-. ------- W -------------- =v.-c�-�_ ,0.._m c%.... 1 -t�.. an •' -� t.�J._1 any 1=_, ._�3.- _.0J fine... -allow U Nature of Repairs or Alterations—Answer when a licable.__.;and. 9.Q!n__12 $II W a3rid U P PP >< .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a OF the provisions of TIT:..i'., 5 of the State Sanitary Code—The undersigned further agrees not to pla RENWICK systteemm 1 qc�r G operation until a Certificate of Compliance has been issued by the board of health. B. v CHAPMAN Signed...................................................................................... ApplicationApproved BY................................................................................................. ............. .0 c«-TE� a ENG Application Disapproved for the following reasons:.............................................................................. TONAL ..--------•------------------------•----•-•-•------•-------.......----.......-•••------•••-•-••••••..•••-•••-•••••••••...--•----•-...-•••--............................................................ Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........Tca N............ OF....-..)�A..ZfO.S.TAB.�..................................... Trrtifirair of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (..--<Or Repaired ( ) b1� - 4 _I_t�l42_... Q.(�g.t� �----------------------------------- ------..........................----•......----...---------........ Installer at-••-••1,, _.._ �r ►, t� _ .s p AT rt---.----G C-•NT ERjJ.J."c-------------------------------------------------------------- has been installed in,accordance with the provisions of T /}` of The State Sanitary Code as scribed in the application for Di"sposal Works Construction Permit No._. _..__.1•f_ _.•................. da.ted---.--1.'"" ~.�� , _._..__.__.. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION pSATISFACTORY. DATE.......... .`... D..�.?.1..:............... Inspector ---------------..---•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.. 7•--�•-/: '_ FEE........................ Di posa1 Endo 'W"fionotrttrtion amit Permission�h eby granted......\r .,n, to Construct ( sRepair ` ( '� an Individual Sewage Disposal System at No. -J'? - ' �i'� -'stg •i�1T 'f� `tt ----------------- as ;;1`•_J-�'� ,.....-�.- 1 ae �t tGLT 3--------�; Y ----- --- � t- l: shown on the application for Disposal Works Construction 'Per 0...... . .. ated............................ ........... -7 Board of Health i r DATE________) FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 7�O SOIL - LOG 670 ( 2 PEASTONE •LOAM s FILL••• 12•MAX • -_ -� - f .• ° I f liDSt�l � cKdS G. f i°, ° I � • 1 is +���? . ,,,•,�;li,.� 4 C.I. DI S T. .,.,.. , 1000 BOX I°•••. I000 GAL. 10'MIN. I° °�,; ° ° °L. 24„ SRC✓ _ g.-=" _ s.�►•,r5�sy ; ' . +;, SEPTIC I°°° PRECAST OR •'° ° I•�• ° • • 1 MIN TANK , I BLOCK ° .I 6 I SEEPAGE - PIT 20' MIN. Boa m' ......I r •.�. FOUNDATION I �2„ WASHED STONE ''•. 1 y .v sr. TES it ELEVATION SKETCH 10' I PERC,,RATE_ UN ,� 2.�a•� .•�c: SCALE I"= 4' ' TEST BY C.o 40N,*X1 cs TOWN INSPECTOR.- �U6 mvAaAtA t BACKHOE OPERATOR: TEST MADE ON : oe 4 } ♦`4. !• G ram • 1 1,7 LSQG�ry POiAf`- I�! /P�i '3tSGr t i f4i �,s. T�," •_ � , 1 !� ` _ y ` • 4 `.,•' i. � • t f �' `� \� 1 ` Bps,-s�/.vo.ca o F' Al III - ' Q� - - . w ..+• r-...^r O w` /,l�S`1r��i•�.p .6?�ID/G� �•,LFJG,II/ - � ,. .�G���/��' . .. ,: '' r',,k: ti ,.� 8AA0_ •00J*,S Guc> FpR6 l�l� c��'r�r�+e x J Jo e�r4C 4 S/s�3 tv.Q.�.Ls /86 S.F h Y.y 6,4114 RI.5.,, r -070 4oG4,Aafr �rToryJ 7'� 5,F x !•o Goc A ` • +'1. To7,°,745 247 S,f, S'7.44143f f,4�tij1A a;qs� RENiN1L'Kr�' . 13 CJj . i . c� CHAPMAtt coi .p^T�o. 21554 •� i r .4 ' • i 'ELEVATION SCHEDULE •' PROPOSED SITE PLAN , �} I. 1NV. - AT FOUNDATION c 8�+ .3� a i 2. INV. INTO SEPTIC TANK = 87• / 8 SEWAGE SYSTEM DESIGN - N f. 3. . INV OUT OF. SEPTIC TANK BG,g� . . �,��H.S'TiG�� �ce,�-r>:~�V/G.GE,�/ /�1/>�.5,$'; - - ' . •, � .a 4. INY. INTO DISTRIBUTION BOX _ SCALE: I"= 2ol SN1 f 19 �4 r II 5. INV. OUT OF DISTRIBUTION BOX C _ 7q r` I. 7 � j' 6. INV. INTO SEEPAGE PIT = .�© CAPE COD SURVEY CONSULTANTS ' I ROUTE 132 , 7. BOTTOM OF PIT HYANNIS ,MASS. j F