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HomeMy WebLinkAbout0309 BUCKSKIN PATH - Health 309 Buckskin Path: 4. ' Centervitle A = 171 - 027 ' IN SMEAD No. 2-153LOR UPC 12534 smead_com • blade in USA �4cyc', 2 �n b9s, N ------ ------. FIFER USED IN THS PRODUCT UNE 5�1 RE OM E M PROGRAM QUIREMENTS SOURCWO VIFkIIAES�ORCi Commonwealth of Massachusetts Tits -5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY Owner --..._.. Owner's Name information is required for every CENTERVILLE MA 02632_ AUGUST 30 2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out formscj on the computer, 1 _ use only the tab Inspector: _ 11 I " a 1. {nsp rn key to move your Q'4 cursor-do not MARK L WHITE use the return key. Name of InspectorCa A.B. CANCO "- Company Na' -me-- zzt Company Address WEST _._ —._... ..._....._.._ Ad YARMOUTH MA 02673 City(rawn state - — - Zip Code 508-775-2820 __--- ____.... S-13381 Telephone Number nse Plumber B. Certification 1 certify that i have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes LJ Conditionally Passes ,��••` f f��ts°r�,, .; ' .• s.. Needs Further Evaluation by the Local Approving Authority `-©' MARK o: WHITE ="= No,S13381 p ' AUGUST 30 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 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspections 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 Offp ciai Inspection Form:Subsurface Sawa isposa!5ystge 1 of 13 t5ins•11110 Commonwealth of Massachusetts Title 5 Offic"al Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH ---Property Address KATHLEENMCCURDY ...... Owner 0;;�—ners-�Fa'�iii inforrnation is required CENTERVILLE MA 02632 AUGUST 30 2011 equired for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.30.1,exist Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass'section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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. OY 7N 11 ND (Explain below): Isins-11MO 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 3.09 BUCKSKIN PATH ------ ------ Property Address KATHLEEN MCCURDY Owner Owner's Name information is required for every CENTERVILLE MA 02632 AUGUST 30 2011 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): M 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): El broken pipe(s)are replaced El Y Dx N 11 ND(Explain below): • obstruction is removed 13 Y FX1 N 0 ND(Explain below): • distribution box is leveled or replaced El Y 0 N El ND (Explain below): El 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 11 Y FX] N 11 ND (Explain below): • obstruction is removed 11 Y OX N 11 ND(Explain below): 154,m-11/10 Form:6ut)5Wface Sow Oge DiSPOW1 System-Page 3 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address �­­ KATHLEEN MCCURDY . ...... OwnerOwner's hlame information is 02632 AUGUST 30 2'011 r1 required for every CENTERVILLE MA page. Cityfrown State Zip Code Date of Inspection C) Further Evaluation Is Required by the Board of Health: 13 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment, 0 Cesspool or privy is within 60 feet of a surface water 0 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: 11 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. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 11 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. t5ins-11/10 Tiue s official inspection Form Subsurface Sewage Disposal System-Page 4 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY Owner 6,��iiWs_Nam�_' information is required for every CENTERVILLE MA 02632 AUGUST 30 2011 page. Citylrown state Zip Code Date of Inspection 3. Other: ........... D) System Failure Criteria Applicable to All System$: You Mu st indicate "Yes"or"No"to each of the following for All inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El Z Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day flow B. Certification (cont.) Yes No n 1XI Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.- ❑ Ell 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. El 9 Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. t5ins-11J10 -ritte 5 official inspection Form:Subsurface Sewage Disposal system-Page 5 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH ....... ........... ...... Prop"Address KATHLEEN MCCURDY ........... Owner owner's Name information is required for every qENTERVILLE MA 02632 AU-GUST 30 2011 page. City/Town State Zip Code Date of inspection 0 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.] 11 21 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system falls. I have determined that one or more of the above failure criteria exist as described in 310 CMR 16.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either'yes"or"no"to each of the following, in addition to the questions in Section D. Yes No 0 El the system is within 400 feet of a surface drinking water supply 0 110 the system is within 200 feet of a tributary to a surface drinking water supply 11 the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone it of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. C. Checklist Check if the following have been done.You must indicate"yes" or"no"as to each of the following, Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? El ER] 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? t5ins-litio Tl,,ie 5 Crffiidvl Inspection Form:Subsurface Sewage DispD,*)System-Page 6 Of 19 Commonwealth of Massachusetts -- Title 5 Official Inspection Form I Subsurface Sewage Disposal System Forma Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY Owner Owner's Name information is required for every CENTERVILLE ......_r 02632 „-_,_._.. AUGUST 30 2011 page. City/Town State Zip Code hate of inspection ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A)N/A ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑x ❑ Was the site inspected for signs of break out? ❑x ❑ Were all system components, excluding the SAS, located on site? R ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the babies 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: ❑ M Existing information. For example, a plan at the Board of Health. Q ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): unknown Number of bedrooms(actual): 3 — - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): unknown D. System Information Description: Q Dumber of current residents: Does residence have a garbage grinder? ® Yes ❑ No t5ins•11f10 Title 5 Official Inspedicn FO.R» Subsurface Sewage Disposal Syst_am•Page?of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH ...... Property'Address— KATHLEEN MCCURDY Owner Owner's Name information is required for every CENTERVILLE MA 02632? AU-GUST302011 page. Cityrrown State Zip Code Date of Inspection ❑ Is laundry on a separate sewage system?[if yes separate inspection required] (9 Yes No Laundry system inspected? 0 yesNo ❑ z yes ❑ Seasonaluse? No Water meter readings, if available(last 2 years usage(gpd)): NO WATER SINCE 2003 Details Z Yes Cl Sump pump? No unknown Last date of occupancy-, Date Commercialfindustrial 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.).- ------ ...... 0 yes EJ Grease trar)t)resent? ❑ No Industrial waste holding tank present? ❑ Yes DNo Non-sanitary waste discharged to the Title 5 system? 1:1 Yes 0 No Water meter readings, if available: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): t6ins-11110 Tiqle 5 Offival Inspec—tion Form:Subsurface sewage Disposal System•Page 8 of 19 commonwealth of Massachusetts fTitle 5 Official Inspect'on Form oSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address Owner KATHLEEN MCCURDY Owner's Name information is CENTERVILLE MA 02632_ AUGUST 30 2011 required for every —.__........ .. -- - ...,_... . .......-. page. City/Town - State Zip Code Date of Inspection General Information Pumping Records: Source of information: no records found_ __.-....... ._--Was system pumped as part of the inspection? ❑ Yes N No If yes, volume pumped: -gallons ........ - - How was quantity pumped determined Reason for pumping: Type of System: p Septic tank, distribution box, soil absorption system ❑ Single cesspool -1 Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) (-1 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 rl Tight tank. Attach a copy of the DEP approval. [] Other(describe): D. System Information (cons.) Approximate age of all components, date installed (if known)and source of information:repairs done on APRIL 19 1991, but no information on type of repair t5ins•i ii io 741e 5 Official Inspection Form:Subsuefaee Sewage pFsposal System•Page 9 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address-------- KATHLEEN MCCURDY Owner Owner's Name information is required for every CENTERVILLE MA 02632 AUGUST..30 2011 page. cityfrown State Zip Code Date of nspection UNK Were sewage odors detected when arriving at the site? 0 Yes Exi No Building Sewer(locate on site plan): 2% Depth below grade: feet ---------- Material of construction: F-1 cast iron 2140 PVC 11 other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2 Depth below grade: feet Material of construction: Z concrete El metal 0 fiberglass D polyethylene 0 other(explain) t5ins-11110 Title 5 Oft:W inspection Form!SubsuffaW Sewage Di*W81 SYMM-Page 10 Of 19 Commonwealth of Massachusetts T otle 5 Official Inspection Form V Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH ................. Property Address KATHLEEN MCCURDY Owner owner's Name information is MA 02632 AUGUST 30 2011 required for every CENTERVILLE page. City/Town State Zip Code Date of inspection If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 11 Yes E3 No Dimensions: 4X8 18" Sludge depth: D. System Information (cont.) Septic Tank(cont. 4f Distance from top of sludge to bottom of outlet the or baffle 0 Scum thickness Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 SLUDGE JUDGE, TAPE How were dimensions determined? MEASURE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK WAS AT OPERATING LEVEL WITH NO VISIBLE SOLIDS AND NO SCUM. SLUDGE WAS APPARENTLY SETTLED AFTER SO MANY YEARS OF INACTIVITY . ......... .......... Grease Trap(locate on site plan): t5ins 11110 7Kle 5 05c01 Inspection FuM Subsurface Sewxle Disposal system-Page 11 d i 9 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY — .......-- ---- ..----- ---- _ -- ----.._.. . ...... Owner -----•._ .,..---------..._.__._....__ ----------- Owner's Name information iS CENTERVILLE MA 02632 AUGUST 30 2011 required#or every _......__ _......._....-__-- _.. . .. . _.__-- page. Cityfrown state Zip Code Date of inspection Depth below grade: yet �_. .:. ..__ Material of construction: ❑concrete ❑metal ❑fiberglass L1 polyethylene ©other(explain): Dimensions: Scum thickness m- 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 D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank roust be pumped at time of inspection)(locate on site plan): Depth below grade: _, Material of construction: ❑concrete El metal 0 fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons _.....____. _.__.._......,____ Design Floyd: gallons per day t5im•71110 tie 5 Official lnspac:ion Fares:5•,.i urface Sewage Disposal 8y5°ern•Page 12 ct 19 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name infonnationi's required for every CENTERVILLE MA 02632 AUGUST 30 2011 page. t�7fovwn State Zip Code Date ox|nonmcion Alarm present: [] Yes Fl No Alarm level: ---------------'--' AJonnin working order: [] Yes [1 No Date of last pumping, -------------- - Comments(condition of alarm and float switches, etcj- � - '-_'-_-_----_--_-__-_------__--__-' ^Attmnhmzpyofcunentpumnpin8montnatt(naquired). \sm»pyadached? [] Yea No D. System Information (cont) Distribution Box(if present must be opened) (locate on site pian): Depth of liquid level above outlet invert AT OPERATING LEVEL Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence mf leakage into or out of box, etc.): Pump Chamber(locate on site plan): � Pumps in working order: Fl Yes No Alarms in working order: Fl Yes Fl No Commonwealth of Massachusetts Tate 5 Offic*alOtt r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY Owner ._ —._. _.. . ..._ ...----- ._ . ... ..—_.__. _ ---- - ..,,. _... ---- O ...... .. .. ...._.--- -----.._..._.. wner's Name information is required for every CENTERVILLE _ NIA 02632 AUGUST 30 2011 _..._ ._. --- --._.__._.....-.•.---- page. City/Town State Zip Code Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System information (cont.) Type: L� leaching pits number: 6X101000GALLONS ❑ leaching chambers number: --- — ❑ leaching galleries number: ------__-... ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: -- ❑ innovative/alternative system Type/name of technology: -- Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5ins•11/50 Title 5 CMI-ia!Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 19 commonwealth of Massachusetts Tftle 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address information is page. CityfTown State Zip Code Date of Inspection PIT IS DRY WTH STAINING APPROXIMATELY 2 FEET HIGH � Cesspools must be pumped am part of (locate on site plan Number and configuration ------- - Depth-hopofUquidtoinbginvert - ---- Oeothofmdidalaymr Depth cf scum layer �---------' Dimensions ofcesspool --- Materials ofconstruction - ---------------------- |nd|cadonofgnoundvveterinOmw [] Yes No D. System Information (cont) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): | Privy(locate on site pla») Materials ofconstruction: ----�' -'�------� ' ----------'---------'-� -� Dimensions - - -------------------------------------- mspomn Form:uubeomceuewe4pumwvmlo*^wo^Page,aw10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY Owner Owner's Name information is required for every CENTERVILLE MA 02632 AUGUST 30 2011 page. City/Town State Zip Code Date of Inspection Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of, the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building, Check one of the boxes below: F1 hand-sketch in the area below Ux drawing attached separately t541s•W10 .".Rspection Form:Subsurface Sewage DisPOWI System•Page 16 Of 19 Commonwealth of!Massachusetts - --_ Title l Inspection Form L - '� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURGY Owner ... information ___.._ .. Owner's Name information is MA 02632 AUGUST 3Q 2011 required for every CENTERV{LLE._..__.. page. Cityrrown State Zip Code Cate of Inspection 1 I D. System Information (coat.) Site Exam: z Check Slope 2 Surface water t5ins•11/10 Title 5 Official InspOct On Form:Subsurface Sewage DI$PMI System•Page 17 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY OwnerOwner's Name information is required for everyCENTERVILLE MA 02632 0 2011 AU...G.....U..ST 3 page. Cityfrown State Zip Code Date of Inspection rX1 Check cellar N Shallow wells Estimated depth to high ground water: NO GROUNDWATER AT 14 FEETfeet 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: 0 Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: PERFORMED AN AUGER HOLE THROUGH THE BOTTOM OF THE DRY LEACH PIT FOR 4 FEET Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist MX Inspection Summary: A, B, C, D, or E checked Z Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Title 5 Official Inspection Form,Subsurface Sewage Dispose!System-Page IS of 18 I Commonwealth of Massachusetts ft- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 309 BUCKSKIN PATH Property Address KATHLEEN MCCURDY Owner --- .__...m_...... Owner's Nae information is required for every CENTERVILLE .— _ _ MA 02632 AUGUST 30 2011 page. City/Town State Zip Code Date of Inspection ® System Information Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file SSYtS,11110 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 19 of 19 i 3� 95 r No.------ .�� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �I TOWN OF BARNSTABLE Appliratinn for Disposal Works Tnnstrnr#inn thrutit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System at: Q C�c. /NYC rt .......................... - -------------- � ........ Location-Address or Lot No. -_-1.�9 ...............` :!_ �Z ...................... .................................................................................................. Owner Addres w 'Vic'-----.- ems tom -" :.. aaF.....R 9 --- ... ..*&:=--------------------------- Installer Addres Type of Building Size Lot----------------------------Sq. feet U Dwelling-No. of Bedrooms.__3....................................Expansion Attic ( ) Garbage Grinder ( ) Other=Type of Building _______________ No. of ersons.....__..____._.._._.._...._ Showers Cafeteria a YP g ------------- P ( ) ( ) 04 Other fixtures ..............-......................................................... WDesign 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-____-_______----------. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------------------------------------------------------------------------------------------------......................................................... 0 Description of Soil...............................................................................------------------------------------•---•-----------------------•----------------------- x c, ---... x -------------------------------------------------------------------------------------------------------- e� -------------------------.i- --------. V Nature of Repairs or Alterations—Answer when applicable ±G___1- ./Obt� �Q� llQ -----------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------------------._...---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with m al Code he undersigned further agrees not to place the the provisions of TITLE 5 of the State Envi n system in operation until a Certificate of Corn been iss a by the board of health. p Signed ------- - --- - ----- -- ................. --------.----------------'` ,. ----------- ................Date .......9--,---- Application Approved By ........... ------. t j�.?� ��Q�!t/�wth� .. to Application Disapproved for the following reasons- --------------------------------------- ------------------- ------------------------------------------------------ .................Date ......---------- PermitNo. 3 V� - Issued -----------------------__.....................................- Date I No....... � �:. 5 b Fss....: .f. ...µ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE n Appfiratiun for Disposal Warks Tonstrudion Vauti# Application is hereby made for a Permit to Construct ( ) or Repair (�,)✓an Individual Sewage Disposal System at: ................--...- •---•-.. ....._.......----•------ ----•-........_... -•---...._........--•---•-•.....- - �...._e _._ , Location-Address 6 - or Lot No. ...........�..........4,...,1_�Y n._...r7;!!).0 (l i_(�� ----------------------- Owner W Address • ------------------------........ ..............__-........__,__ -----------... ----NN.....AN -----....-....... ............... Installer Add__ressy Type of Building Size Lot____________________________Sq. feet U U Dwelling—No. of Bedrooms.•.,3....................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building -------------_.............. No. of persons............................ Showers ( ) — Cafeteria ( ) P4 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. 3 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........................ Lr., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -••••----••----------------••-•-•-----••-•---•••----•-•----•---.....----•-------------------•-••-•--......................................................... 0 Description of Soil......................................................... ------------- ------------------------------------•---------------------------------------•---------- �C W ------------------------------------------------•-----------------------•-------------------------------•---------------------------------------•-------------------------------. • U Nature of Repairs or Alterations—Answer when applicable._��.: R __-1-_aP-__106b__._-l� "___.. `W _? .� : -•-------------------------------------•---------------------------------------------...._.._.---•----•-----.....------------•------•-•-•----•-•-•-•-.................................................. Agreement: r- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Enviro mn en-tal Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed --- - -- fZ---- 1 .Y, -...-.Date Application Appro BY -4�,- � �•... 11 V . -----...---'--- ------------------------ -Application Disapproved oved for the following reasons: -------------------.....----------------------------------------------------------------------------E- ------------------........ T Date Permit No. ...... f.-..-I Issued ----------------------------------------------- - ....... r --•-'-----.................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#if rate of (gontylinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ...............Fi-°�---�h----.....C'a-l . -4�......1-h'-c'.................................................. -Installer at ------- 0-9..... t�C f<... .K 1 +'----------�r-'?8_77l------------------------------C. et7 .......................------- ---------...................... has been installed in accordance with the provisions of TITLE 5 o�The State Environmental Code as described in the application for Disposal Works Construction Permit No. ........•..- .-...1.. -5.....--.... dated ...................__......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. SD DATE ------"- ------------------------ Inspector ..... ---t. .......--------------------------------------------- C."--�.... ..-f- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1•- I..•3� TOWN OF BARNSTABLE No......... F$E•••--••-_. Disposal Workollonstrurtion prrmi# Permission is hereby granted........).Q.7�.2.....CH LQ........�.r C'......................................................................... to Construct ( ) or Repair ( 1�).-gn Individual Sewage Disposal System atNo....r7,0.9 ............................................. ................................. Street �� ` as shown on the application for Disposal Works Construction Permit No..�__>._./..�_.... Dated______________ .. .....................................�6 ............................................. ..._ ................__....._._........ ` `� Q� )Board of Health DATE................ .... /---......:1--r----------------------•----•---• V FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS O / TOWN OF BARNSTABLE 1 LOCATION 309 �UG(.cSbfin l'/Q'f'bJ SEWAGE# VILLAGE ����e%yI �C� ASSESSOR'S L( QD INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY tI Dh 8 LEACHING FACILITY:(type) L!" 106 b (size) 6 xi o NO. OF BEDROOMS PRIVATE WELL O PUBLIC TER BUILDER OR OWNER Inc ad'v DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r Yy4 3� 95 �C/r