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HomeMy WebLinkAbout0382 BUCKSKIN PATH - Health 382 Buckskin Path, Centerville 191-132 No. 42101/3 ORA � o . p o ESSELTE 10% O © a 0 r. Y" Commonwealth of Massachusetts to Title 5 Official Inspection Form ; 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path h V Property Address -, Robert E. Baker Owner Owners Name / information is Centerville V Ma 02632 6-17-2020 required for every 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 filling out forms A. Inspector Information v5/* on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 411111 374 Route 130 ua Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 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 Brett Hickey Digitally signed by Brett Hickey i Date:zozo.06.tsoe:39:58-on'oo• 6-17-2020 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 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 c Commonwealth of Massachusetts ' Title 5 Official Inspection Form �= I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path u� Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every, page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑� I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 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 ❑ ND (Explain below): t t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N- ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ` ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path u Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) .E1 Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ,❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) • Yes No ❑ Q Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El 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. ❑ Q The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 c Commonwealth of Massachusetts � Title 5 Official Inspection Form ?= �4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments + 382 Buckskin Path Property Address Robert E.Baker Owner Owner's Name information is required for every Centerville Ma 02632 6-17-2020 page. City/Town 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 El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ a 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) ❑ n Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? ED ❑ 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? ❑ a 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: El ❑ 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 ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD Description.- Per permit dated 6-5-1996 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes 0 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 El No Seasonal use? ❑ Yes E No � Water meter readings, if available (last 2 years usage(gpd)): See below Detail: 2019- 115,000gallons 2018- 131,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: currentDate t5insp.doc•rev.726/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 14A, Commonwealth of Massachusetts �m Title 5 Official Inspection Form r5 � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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? ❑ 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: Owner- last pumped 3 years ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path V� Property Address Robert E.Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ' ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe).- Approximate age of all components, date installed (if known)and source of information: 1996 per permit Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form G ,1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A °4 382 Buckskin Path Property Address Robert It. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑Q 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 1500gallons Dimensions: 611 Sludge depth: 3011 Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 161f Distance from bottom of scum to bottom of outlet tee or baffle �. measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc°rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �- ,e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '0 382 Buckskin Path �v� Property Address Robert E. Baker Owner Owner's Name information is Centerville , Ma 02632 6-17-2020 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: NAfeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day i 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 w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path v Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 .Am Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 382 Buckskin Path u Property Address Robert E.Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town 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.): NA If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 4'x60' Q leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system - t Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path u— Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every 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.): The SAS was in working order at the time of inspection. No evidence of past back up was observed., 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path u Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 - -a w Commonwealth of Massachusetts �9 Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 4,,.382 Buckskin Path ,,Property Address Robert E.Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required forevery 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 I A B. .z A1.27' B1.41' A2.47 B2.53' A3.37' 0 83.59' a - 3 ' > 2 ' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Buckskin Path v� Property Address Robert E. Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑W Check Slope X■ Surface water Wil Check cellar ■❑ Shallow wells Estimated depth to high ground water: NO GW @ 12' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on recard If checked, date of design plan reviewed: Date El 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: Bottom elevation of SAS was determined and transfered with transit to low laying area showing bottom of SAS is above high ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 f Commonwealth of Massachusetts �ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u >r 382 Buckskin Path n Property Address *Robert E.Baker Owner Owner's Name information is Centerville Ma 02632 6-17-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ■❑ A. Inspector Information: Complete all fields in this section. ■❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i< t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 y 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form =#` Subsurface Sewage Disposal S r Frst°rrr...dv& i,l �m fol''yo,r ntary AssVs,:rnents Property Address Ou+fner CWners Na -- ✓r? be information is me N ` r --- j prequired efor every //?' !Y� 0� Page- �yl1'own ---- ��� State: Zip Code Date of spec n 54 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. Mportf When A. General Information Ming out forms /c'0 Q on the computer, / U use only the tab Inspector. key to move your 1. cursor- et not o /.S-� use the return Q►r key. Name of inspector anpany Narne Company Address J Qryliown Oo? oZ State Zip Code _ �o�a Telephone lNurnber License Number B. Certification 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 DI_P approved system inspector pursuant to Section 16.340 of Title 5 �10CR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspecto 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 S0,GGO god 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 aescribes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title5Official I specdcnForm Subsufaoe Sewage Disposal System•Page 1 of17 Ld � t Commonwealth of Massachusetts Title 5 offic,ial inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Roperty Address Ow ner Ow ner's Name 6�✓7 2 �r o information is required for every H4evri!le / IA oa Io3d, page. City in State Zip Code Date of I s B. Certification (cons.) pectlon Inspection Summary: Check A,B,C,D or E/always com plete all of Section D A) System Passes: L�l 1 have not found any information which indicates that an of the failure in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not cevaluated 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 ex0ain. 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 existiro tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): a t5ns•3M 3 Title5officiallnspecdcnPorm Subsurface Sewage Disposal System-Page 2of17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form A Not for Voluntary Assessments Property Address Ouv ner information is Owner's /� required for every �� t�v�!(� 1' //9 page. Crtylrown State Zip Code Date of spec n B. Certification (corn.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 343 riitesoffidallre fionFormsubsurfacesa sava ge vr�g Disposal System-Palge3oflT Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39Q 6 Property Address — O,v ner Ow ner's Name G w12 �/U information is I /4� Da 6 required for every c�-!�✓tip I� page. ( ylfown State Zip Code Date f Ins tion B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ��Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ��Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/day flow ��-313 T1050fficlallnspectionFanc Subsu7aceSewegeDisposal System-Fage4of17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �y G �YcS��r v► �� / "/ Property Address Owner information is �"naps Name required for every Ceu-16K /V.! ` le 014 ?j 6o / � /.` page. C /Town State Zip Code Date Of ftp&Wn B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Eff"' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L'J 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.] ❑ T e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ElThe system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`fires"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of.any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. O s•3(13 rifle5Official IrspecfionForm SubswfaceSavageDisposal Sptem•Page Sof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ✓d oC 'J�t G h�J Nl t�i �o.'� Property Address OW ner � ►'yam �1 O information is ON nees Name jj /required for every CPS AFC✓v,` ,e page. CdylTown State Zip Code Date of InspWion C. Checklist Check if the following have been done. You must indicate"yes"or"no'as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ s the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 for example: 110 �� ( p gpd x#of bedrooms): tSrs-3M 3 Title 501'ficial Uspectian Fart[Sutuuface Barrage Disposal System•Pie 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not ibr Voluntary Assessments yj Property Address _ information is Owner's Name required for every C Z �/ ✓►�vl 14 AU oa page. City/To fn State Zip Code Date f Ins tion D. System Information Description: / i'e 611 C,1, Number of current residents: C� Does residence have a garbage grinder? ❑ YeS Is laundry on a separate sewage system?(Include laundry system inspection �� information in this report.) ❑ Yes 9- No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes 9_140 Water meter readings, if availabie(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes Fa- No Last date of occupancy: G1,y/hcr _ Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203), Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 3 Title 5 Official Inspection Form Subsuface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachuset Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not Not for Voluntary Assessments 3�p� ��GZGNS��H Property Address ON na &�f O ON ner s Name // informaton is required for every A4 page. Cltylrown State Zip Code We of spectlofi D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: 02.o tom. o�„�►.,-✓ 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: Type 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/Aitemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other (descri be): tyns,3113 Tifie5Official Inspection Farm Subsurface Savage Disposal System•Page Sof 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3-ya &4c k,-r Property Address /� Ow nerQvl�vieo information is ner's Name / required for every (,2✓► �i`/ /- 0a63� page. Cdyrrown State Zip Code Date of spec n D. System information (cont.) Approximate age of all components, date installed(if known)and source of info ation: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): O e/ Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): i Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Materia 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 L-2 Dimensions: Sludge depth: / Mrs-3H 3 Title 5 official Inspection F om[subsuiace sevage Disposal system•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments Property Add W C LAI,1 ress --- oIv ner infomvtionis Owner'sName /� / requiredforevery C�2�t- ✓veGle /�j4 (�02(,3� /� �� page. Qty/Town State Zip Code Date Ins tion D. System Information (coat.) Septic Tank(coat.) 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 �— > How were dimensions determined? o le Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): VJ VVII h -e J, G'^`)✓ A v+c� Tees /Vi Ott '.ec'4_s Grease Trap pocate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ns•3H3 Tide 50fficial InspeetionFonrz SubsWaceSevMeDisposal System-Page 10d 17 I Commonwealth of Massachusetts lug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2� / a 44 Roperty Address / Owner CG ✓"le- /f o information's �ner's Name I_ �j required for every Ceo`fit,t/ /le //� L c h 8// page. GWffown State Zip Code We of Inspection D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 4 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No On 3h3 Tiue5official InspeofimFartn Subsurface SevageDisposal S)sWm•Page 11 or 17 i' I ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not far Voluntary Assessments Property Address ON ner Ow ner's Name // information is C e w- lVw i l G Al e �-6 required for every page. UFfrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (f present 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.): /yo Z" So/l s Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: tSirr•Y13 Title 6Ofticial Inspection Form Subsurface Sewage Disposal System*Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not ibr Voluntary Assessments v �� GtG�iis�✓i✓I �7.�/ Property Address Ow ner information is Owner's Name C CJ I O required for every �y Ile, page. !town State Zip Code Date Ins D. System Information (cont.) motion Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ eaching galleries number. / leachi ` ng 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.): 1'i2 cillei 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 Sm.•3M3 Title5offical l speolionFom=Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection ct'®n e p Form Subsurface Sewage Disposal System Form Y Not for Voluntary Assessments Property Address /r`s/o✓I Ow ner Owner's Name C et `M� b ion i ! � /f�requiredquQed for e every (�e �-e✓v / "/� DoZ G 3.Z �o / /6 page• CdylTown D. System Information (coat.) state Zip Code Date o Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ns•3M 3 Ti#e5Official Inspection Farm Subsurface Sewageoisposal Sysfam•Page 14 of 17 I` I ' Commonweafth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5�� r�Gt G[�5 �i�✓I /-1 T Lj Property Address Ow ner Owners Name information is �required page W� ? 2 CI !S page. CCYtyyllown State L Z�Cale Date Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Pm%Ide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below. hand-sketch in the area below drawing attached separately G c2 Q t5rs•3f13 Title 5Official I specficn Fartrc Subsuface Seviage Disposal SYsfam•Page 15 cf 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address information is r►er'S N2me l requvedforevey 2rn Lev, .e A�C4 01)-6 3� Co Page City/Town State Zip Code Date f Inspection D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells C) / It.-o MXL Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ bserved 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 USCS database-explain: You must des 'be how you est blishe/Id the high ground water elevation: 41V /10L4o OT- e&i O-e <D t✓ d2 - Aeo VIE A t, iJ Before filing this Inspection Report, please see Report Completeness Checklist on next page. tSns•3H3 Titie5Official Inspection Form SubsurfaceSevegeDisposal S)Mm•Page 16017 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage sat 9 DrsPo System Form-Not for Voluntary Assessments 3P.) Ra 7w Address Ow nor Ouv ner's Name I � of rr! (�/!o iftfomatim is requpage. dforevery 2vt dv6 ��G � ) page. C�ylTown —�_:_[ o� E. 7:ftomaction Coanpie MSS Checklist cue tee ' Summary:A, B, C, D, or E checked Su mmary D(System Failure Criteria Applicable to All Systems)completed em Wrmation—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file IGts•3H3 Tme50ffta1 JMPGCdMFCrM SuhWaw SewgeDLV-a Sys*m•Pape 17 of 17 E � , . :. .,.. � � a'. . . 17 TOWN OF BARNSTABLE LOCATION 3q 2— 6LA--ks�i h pl*ti SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY c LEACHING FACILITY:(type) t T to f'c� (size) 60 ?� 1 NO.OF BEDROOMS OWNER sT91l c1 r LV N PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. O + 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 ECo - l C rl T�`U ECI t noa �Z� 93rt W ASSESSORS MAP N / :; 40 . 00 1\� Fee '�" THE COMMM44 TTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,'MASSACHUSETTS 0[pplication for Oi!9poot *pgtem Con!gtruction Permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 382 Buckskin Path Mr. Klun Centerville 775-5809 InstaV'sgame.AdV.5s,and Tel.No. Designer's Name,Address and Tel.No. Kto inson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(nq 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 Description of Soil sand Natu f Repairs or Alferatiogs(Answer when applicable) install a 1 , 500 septic tank, (73ox and 4 x60 leachtrench. Pump and fill old cesspools. 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 this Board Health. Signed .,/ , � Date 4!� — Application Approved by Application Disapproved for the follows)g reasons Permit No. �!©�'� Date Issued :. 4 0.0 0 o. I{ � Fee 4 THE COMMONWEALTH dFASSACHUSETTS PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE., MASSACHUSETTS , �a 01ppYication for ] igool *proem Construction Permit Application is hereby made for a Permit to Construct,( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No-1­ Owner's Name,Address and Tel.No. 382 Buckskin Path Mr. Klun Centerville 775-5809 InstalJe g:me, 1dgj,and Tel. .Septic $erV Designer's Name,Address and Tel.No. WWP.O. 11BZZox 1089 Centervillp Type of Building: i Dwelling No.of Bedrooms g-ZA Garbage Grinder(nq 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 Description of Soil sand Nat u f Re airs r iller s nswer when applicable) install a 1 ,500 septic tank, dre 3oxP anc� 4 x0.... _7eachtrench. Pump and fill old cesspools. 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 this BoarV Health. / Signed �" E Date G. —s- Application Approved by —g Application Disapproved for the follow' g reasons r Permit No. `7 �O— //f Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance { THIS IS TO CERTIFY,that the On-site Sewage Disposal'System installed( )or repaired/replaced(x )on by W.fe Robinson Septic Sery for Mr. $lun I - as Bucks in Path Centerville has bdn constructed in-accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set fo • low: A y 7 40.00 No. / Fee Klun THE COMMONWEALTH OF MASSACHUSETTS f PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1Wi!5pogar *pgtem Construction Permit Permission is hereby granted to W.E. Robinson septic sere to construct( )re air( X)an On-site Sewage System located at 382 Buckskin Path Centerville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Approved by r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, hereby certify that the application for disposal works construction permit signed by me dated � �— a l cottcerniri$the property located at 3 130 c KS meetai^e11 of the following criteria: There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. t2. 1 z r. 4" SIGNED: �� DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER a n k [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certifled plot plea, this plan should be submitted]. � _ 5+ hLT - N S AM } P � 1 0 61et 1 r Y TOWN OF BARNSTABLE L L.0CAT1ON __s 51 P- GL' ll-s W SEWAGE# �✓ J 'V7—LAGE G,�.�T !-/GGf-" ASSESSOR'S MAP&LOT% � INSTALLER'S NAME&PHONE NO.t&W, if 44,6/IVcS Al 77, &V 77 SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) �X• (size) ���NO.OF BEDROOMS S BLM09WOR OWNER / +�• � ®l / PERMTTDATE: COMPLIANCE DATE: 46 :6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' g ility) Feet Furnished by G �. � _ L x- - 0 53 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE- �� iQ [ ASSESSOR'S MAP & LOT, INSTALLER'S NAM$ & PHONE NO. a SEPTIC TANK CAPACITY F} LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes r° '` No�®