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HomeMy WebLinkAbout0406 BUCKSKIN PATH - Health 406 Buckskin Path Centerville P A = 192 124 ,r No. 4210 1/3 ORA Pendaflex' 100 t To ti Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 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. A. General Information 1. Ins ector: P moo Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local proving Authority 8-18-14 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 DEP. 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 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. i t5ins-3113 Title 5 Official Inspection Fo ul ce Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 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 15.304 exist.Any failure criteria not evaluated are in dicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: I ❑ 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): t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 1 C Commonwealth of Massachusetts m W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection 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 town 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 '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 • l i Commonwealth of Massachusetts W Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: 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 ❑ ❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection 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? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was.the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �qM 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8-2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Savage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M s 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1977 with extra pit added in 1990's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ® cast iron ® 40 PVC Orangeburg ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 1000 galfeet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal; list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cont.Tank Septic p (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G'M s 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection 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 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 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 t5ins,-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): 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 Ian excavation not required): P Y ( ) ( P If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form �m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-1000 gal ❑ leaching chambers number: N f ❑ 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.): Both leach pits in good condition with stain line in second pit at 40" below inlet invert. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City[Town State Zip Code Date of Inspection 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: ® hand-sketch in the area below ❑ drawing attached separately lb t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments GqM 406 Buckskin Path Property Address Annette Marshall Owner Owner's Name information is required for every Centerville MA 02632 8-18-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 'TO"b F$ARNST LG rile A.9SIES OWS MAp&LOT-1_. 1 INS.TPIR S NAIME&ptrpl'TE N0 --- ------�-�--- SE C �'A iwil CP 3F CITY L3EACIiITG k�l�CII'I`Y (tp3) NO OFBrl-pIZC36j1! BUILDER Sep >tratTogr TstiTTar,�Bctvree:�tlne Nl�ixu�tum l�.c�j�st�d G�aTaTR�3w+�t��'L'�ble to tlbG l3rn.takn.al�.�ac;htn�k?�c;ilit� .�-�.,� �— Leer e " �'i39TTE ETC91;t ::. Thfily'C�1NJ19St.,. t ., .. �� Nuv ac; °Jdt�t�.r dupe!! do l:aUd YMi~a .., Y Fool i T±c IQ ii;<r�VVrtYanrl shad ILeA �>Ta► acallty GYM an a{ctAancixTst. tvlltzTit {?�u e t teT►c yf ng,policy) �lc Cc Roo 00 yy� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is Centerville MA 02632 07/11/11 required for every page. Cityffown 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 forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections gyy Company Name PO Box 896 Company Address East Dennis MA 02641 Cityfrown State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification lAJ M ` I certify�rthat I have personally inspected the sewage disposal system at this address and that the C ,F information reported below is true, accurate and complete as of the time of the inspection. The inspection e� was performed based on my training and experience in the proper function and maintenance of on site Z= sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of cD Title 5(310 CMR 16.000).The system: U.- CD mow;; ®( Passes ❑ Conditionally Passes ❑ Fails CD t ❑1 J�leeds Further Evaluation by the Local Approving Authority 07/20/11 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 DEP. 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 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. f v ellb � I t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewag isposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is Centerville MA 02632 07/11/11 required for every page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information isrequir Centerville MA 02632 07/11/11 page. for every Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityrrown State Zip Code Date of Inspection 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'/z day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. City/Town State Zip Code Date of inspection 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: 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 ❑ ❑ 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. t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Properly Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityrrown State Zip Code Date of Inspection 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? ® ❑ 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 El ® 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 ® El 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Titie 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No 05/11 Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: t5ins-11/10 Title 5 official fnspeclion Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �y 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is Centerville MA 02632 07/11/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Tltie 5 Official Inspection Foam Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 20 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.6 Depth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2.0 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 4" Sludge depth: t5ins•11/10 TiUe 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle T' Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured 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 sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. City/Town State Zip Code Date of Inspection 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 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 working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is Centerville MA 02632 07/11/11 required for every page. Ci crown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if 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.): No box present 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.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is Centerville MA 02632 07/11/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: 9p leachin its number: ® ❑ 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.): This system has a 6'x6'precast pit surrounded by a foot of stone. There was no liquid present with a stain line twenty-six inches up from the bottom. 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 t5ins•11/10 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 (J� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan OwrW Awriees Name irrfonnauon isrequCenterville MA 02632 07/11/11 page- for every �y�� StMe Zip Code Date of fr>spection Pam- D. System Information (cunt.) Sketch of Sewage Disposal System:Pro vWe a view of the sewage disposal system,including ties to at feast two parmarmog 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 5� a� l9ns•tUtO Ti9s6Otfic7elMspec6, F0WSW-M -81-W SyBMn•PW15d17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is required for every Centerville MA 02632 07/11/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 30.0 Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Wealth-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 30.0 feet. Before filing this Inspection Report, p p P lease see Report Completeness Checklist on next page. p p t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 406 Buckskin Path Property Address Jean Ryan Owner Owner's Name information is Centerville MA 02632 07/11/11 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f (- 9 D ATE : 10(21 /03 PROPERTY ADDRESS: 406 Buckskin Path Centerville ____--_--- Mass 02632 1� On the above date, I inspected the septic systern at the above add Tnis system consists of the following: RECEIVED 1 . 1 -1000 gallon septic tank 3. No d.i.6t2i9ut.ion Sox. 1 20�3 2 . 1 -1000 gallon leaching pit. NOV 3 Baseo on my inspection, I certify the IOIIOwing condlllons: TOWN OFBARNSTABLE 4. 7hi.e .ih a t.ii_ie 1-ive heptie ,zyztem. ( 78 Come) HEALTH DEPT. 5. The zzpt.ic .sy,stem .ins in /2ao/2e2 wo zking o zde2 at the /1aezent time. 6. Ua,ste watea .iz 24" geiow the .invent /2.i./1a o�R_ the Peach.i.2y pit. SIG NATUR 77d----- - -- - - - Name _ _:_ _ P_ _Macomber_ Jr _ ___ - : orripany : )Qgtpn Son, Inc . caress : _ _@Q�s _� - ----- ------- • P ^ one 50a . 775_ ) ) 38 _ _ __ _ _ __ T„iS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY )OSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-leachllelds Pumped & Installed Town Sewer Connectlons P 0 Box 66 Centerville. MA 02632.0066 115.3338 775-6412 ' COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 406 Buckskin Path Centerville Owner's Name:Conrad Johnson Owner's Address: same Date of Inspection: 10 2 17 03 Name of Inspector: (please print) aoael2h /). Macomgelz a/L. Company Name: a• P. Macom el, 02 nc. Mailing Address:Box 66 Cen�elLy-iiie, l'1¢,3.6. 02632 Telephone Number: 5U8-775-333�8 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: xx)Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: , Date: The system inspector shall ebmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 CIEE'tCIAL INSPECTION FORM. — NOT FOR VOLUNTARY A.SSESSNIENTS SUBSURFACE SEMIAGE DISPOSAL SYSTEM INSPECTION FORM PART A �:ERTIEICA I IC !"�T (continued) Property Address: 4j!� aUS: 5 ri t.iv,'ner: Ccilir-ad :lolarlsgn Dale of inspection: 1 0 Inspection Summary: Cbeck A,B,C,D or E/,�.LWA t'S complete all of Section l) ACS),stcrn sey� _ i have not found any information whic?i :indicates that any of the failure criteria described in 3 1,0 C1vtR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. C'ornmerrts; t fie. 2,, n,! L12� ii/LQe 2. i? C/7.Ue 1 L7.4 eo , -� >-� B. System Coriditionaliti,f`asses: �U One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon coiripietion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the-for the following statements. If"not determined" please ::xplain. "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 extiltration or tank failure is imminent. System will pass inspection if the existing-tauk is replaced with a complying septic tank as approved by the Board of Health, `A metal septic tank will pass inspection if it is str-ucrurally sound, not leaking and if a Certificate of Co indicating that the tank is less than 20 ;ears old is availably.. N D exi7!aLn: )bserValtGri of s(',vage backup or break out or high static water!eye! in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. Systern will pass inspection if(with approval of Board of Health): broken pipes)are repiacer obstruction is rcmover! _ disvibu'tion box is !tvei:d or rcolaccd ND exp1a.in; The systern required pumping more than 4 ti.mes a year due to broken or obstructed pipe(s). —1'he system will pass inspection if(with approval of the Hoard ofl-leaitit): broken pipes1 are.repiace.d _-- obstruction is removed N!:) explain: ,i Page 3 or i i OFFICIAL INSPECTION FORM - NoIf FORlIOLTj-.,"'l"ARY ,.�SSESSNIE"'ATS SUBSURFACE SEWAGE DISIPOSA.I., &YSTE)"i INSNEC'1110N F.'OftNI RT A I A CERTIFICATION (,:orltinu?d) Property Add�ess:4-406PBge �itl, Date of Inspecii0n: -�d by the Board of !-I e' Further Evaluation is Requi! 6"4) Conditions ;,Xist which ruquirt!. [u!-,j(c! eyajivaj;ojj !)y dhe Lioetri of i-lcalih 61 order o determine if the system; IfIli!Lng to protect public nealrn,, sartty Ur the inviron-ment 1. Systerri will pass Li less Bc;ard of Health determines in accordance with 310 CMR 1'",-3030 )(b) that oic -:,Sl-zrn is not fun ctionin 9 in 3 M2011tr N'hich will protect public health, safety and the environment; Cesspool or pri,*-,,is within 50 rnct of a Surface wilter Cesspool or privy i3 w i n ,k) tert of J vegelzi-(ed vveilajid or a salt rna(sh 1. SN—Mefil wi!l fail unless the Board of'Health (and Public Water Stirtpiier, If dc(rrnines that The is in -a n1allner ?Teat prOfects !he public I ealth, safety and environment: sySlcrn ha= a sept;:, tan": "Ind, Soil abSoi-ption system (>tiJ1 and t!e 'AS i t 11 0 [e e I of a surfacr: water supph,or (ributarr, !6 a sue face water supply. wstdrn !.,.as i,. 5(:ptic lint. and SAS wid the S/,6 is NN,i t h i n a Zone 1 of a P L-ib i w a I s u P 1 y. n h� 2 -,xp(ic tank and SAS and is within 50 feet of a private water supply well The S A S systern has ,.i Septic 2 r-Ll- and, SAS ai-id the SA s less than 100 fper but �,o fe-�t cq r,-jore f,,-onj a M�Olod Us�d to delernliin- dislance 'This sys!"'In pass�n. H — . !K ".C1. tv�..er armlysis, perform,d at a DEEP certified laboralory, for coilform bac(,.ria vvi:;t;;� org �. i I Pi�i.r comqound� indicates Ulai the -weill is free 11-om pollution from that faciliry and the presence or Irnm0ma nitrogen -and nitrate nilragcn is equal to or less than 5 prm, orovidcd that no other failure cFitel-la arc Vi g,cicd. A Copy of the analysis must be inach;-d to this form. 3, Other; Y Page 4 of I I OFFICUQL INSPECTION FORM-NOT FOR VOLVNITAJ Y ASSIES4-SMEiNTS SU13SURFACE SEWAGE DISI'OSA.L SYSTEM INSPECTION FOR.JM (continued) CERTIFY,CA 11 O� Property Address: 406 13uckskjn_PqQ-t I)Iiie Of 11151)Cctifun: 1 O�/21 103 D, System Failure Criteria !ippllicitwe to all Symms: You MILLt i)dicamc"yes"or"no" to each of the follo-,,eing for AL11 insptcdorl.s: Yes No/ -B-,tckupofsewage into or clog?cd SAS orcesspool sux�*acc Nvatensdul: wan ovt!joadcdor 6qged SAS orrcsspool f,kjAKj. Swic lquid leaf K Me disAWK box above (?inlet in Veil due to ar, overloaded or clo"td SAS or cesspool 'LlAw )-iquid depth Ln is 1css Mmn 6" below tn-,,cr, or available volurne is less (jay flo,-V Required purn PiJ9 more Oun 4 times in the As! year NOT due W clogged or o1bmT-u(.-!cd pipc(s). Nunber tinle, Any poUn of the S A V cesspool or privy is btio\y ground watcr flCyadon. yponion of ccsspool or privy is wit)iLnj 1()Ci (et.,t of jj s e -)ppiy or tributary to a surfa c c kn, W-rac water vvwcr supply. IfnkAny portion a cesspool or p6n, 4 a Zone w ofa pubHc ell. 'rill Any portion or a cc"pooi o, qw, is vithin 50 feet of 11 prj qte wmer supply well. Any portion o[a or Privy ii !ess Man 100 be! but greater Uhan 50 feet from a private water sUppl.'-, Well with no acceptable water quality analysis. Rhis system; posses if the wcH water analysis, perf-Drined at a DEP cenind hborvwo for conform bacteda and Y010114 "gunk compounds indicates that the well h free frorn polit"Jon from that facility and the presence of arnnionia nitrogen and MUM nRmgtn 4 equal to or im than 5 ppm, provided that no other failure Kledii are triggered, A copy or the zrijIysjs a)ust be 10 this form') (Yes,No) The systern Nil, 1 han a detennirled Unt one 0.-.- rr-jorc ofilit above f,-alilkirf cri(eria cxist as &�sr..Fib?d in 310 CNIR 15301 thenl7ore At *01cm bill lie system owner should contact the Bf,,ard of HeL 1 110) 10 delcriniPc what will b,- necessary to correct o f i c urc. L Laqc Systems; To be considered a large qilern the system must serve B facility with a design now of 10,000 glad to 15j00 gpd. You mum indicate either'les"or"no" to each orthe following: (The f0llo-il19 criteria apply to large, sysitrns in addition to the criteria above) yes no/ Melt 6 W&Nn 400 fAl of a suricr drUlking v,,atcr supply ,xthe syst-rn is Within 200 left of a tribuiary to a silrl'ace &LnXing water supply the symern is located in a niLTogtn sensitive area (Interim Wellhead flroto�ction Arta- 1uTA)or a mapped Zone H of a public water 3uppi), well if you have ansyTred "yce' to any quesdon in Section E the System is comicred a AnTcaM Bew, or answemd 'des" in `:,cello(! D above the large system has fai!Qd. "Flic owncj-or opel-atol.c)., any jjg-c systcn-,. considered ,-. Qnircaol lu,,, under Section E or failad under Section 1) shall upgrade. the. system in wxordarxe C, 15 3% rile "Itern o"mer should conso the aPrOP&M M95MI oMox of Me Dqwnrncm. f Pale S of i! , OFFICIAL INSPECTION POI~M—NOT MR 'VOLUN SUBSPACE SEWAGE, EaSVOSA_I.,SYS'!'IEN! Ilgy yc"1'•t r^>l . R T )D Property Address: owba.Conrad J_ ohan on DPt:nllospGrRfnn. 1 0 �1 �J3 t: Chcr.k 1Cf}le follou+{siZ -ve bwen dont, You must indicate s„ Gt.,•noo, rs to . a ti l::<i __ /��/�1tCe vt!y0�1 ;g ;Yd EdCI COt71pt,{}e!}lS yLl71j?Gd+0,ut Ul ;hG prtYiouS t, e '•; cc;.; �� }{� �1s system rcceivtd normal !lows �n t11G ;arc:i;pus r,vo �w'cc�: + ' E�i1 Yt lark( Voiu ;ts or1vucr bccn innodl CCd to tic sysmrn "Wy w ! /-Wac zs built p!uis o is?G 5;<tCRi i)i)s& 1Sd 4!.,d o"AIni'1Cd? (i(Only „c(C nol 011 1'1CillrY pr dw6in ingpn rIcd for _ eras the site {rlspcocd for Signs of t?rta.k oui ? /...Y. Wert 0 Sysim cnmpone r t n..i; 1 ;� •. I•te ir'. OCL!a;d G!i SiiC Ii �iiCr: (he 5e do ; !,% (Titr",n1,Qlo uncovacd,,apancd; end the jNjaji i of'he Moo or tree, rr .�'eS f Ct) UYnrr,21Y )ccupy ri ` r WARM ow UcC� `''._.�" is .. . . .., �COY!•J:J '.r,t: „U::t'.: riia:llttnanCe O�SiUSU.!ia�:t iC'r4'1if Uli�)US3i ;b'St.[[1S �) the Stle And lowlo,n, or 01 Sol! Absorptkn Qum (SAS) on Ou „(C hu }•.e!n ;l:i,:Cl'it,.. .` _... . . .. ,l(ts no A —t1 Ex.lStlilt` jnIc.-a (ion. For tk&m.�,1G, 8 p oz ato Di:.:d oT!`r.:: 'tj J� Dckanin?d I the MW (My or m Hoc +:Cti.'I ;i.ud ; _. C 1s 'JndCCU bi. Y • I P"gC 6 or 1 OFFICI,kL INSPECTION I FORM - NOT FOR S U B S T=,!,!ACE S�:`)Y A C�- DI S P r-,S,-Al J'TSTE�rl I N S P ECT I 0,1� p C,,,jr��M FART C z',"',,'S'l-E i,,i IN F 0*.r ,IAT 10 N P"PeVjAdd"s!: 406_BqckstLn PaLh Diu of KE SIDE NTLAL FLONY CNADITIONS Es!c�,, no,.:. 'o&scdo, 310c&QQ 15103 (for :xlmplc: 110 gpd x k of—10C&Oorns): ,D E Doc; rekdenct hive I Wgc PAW (yes or no): hill IM17 OM I StPL"It Sewage systern (Yes or no):72 [i(Ycl 5eNrUc Ul5pcctlon rcquu,d) (yes or nq:jj!- "Va:cl men[ reldungs, if (Ils( 2 u5ay Qpd)): 1 21 , 000 go C Kao 33 i. 5 AmP PWU (It w no: 40 g2ilonz=287. 68 qPLD) L is i d a n o f oc C"j".,&-'I'Y: (I I C 0",1-NI K R C L,,Lf LN"o U S'l"PU A 1- c n 1: Design now (based or, d as i gn n (yci or no,,on"')- ;'i�V5iTla1 tivb 5 1 c by 1 di 119 to rlt', prr S4nt (y t s Or no): o �lniwy wls(! dis.'J.krg'� to t�'le Tili` 5 n IL Want mcar Whgq if unit,Wc J-1 (yes o r n o): Last din of occur tj,,c-,,/u5r: OTHER Newrilocy P-im a Pirl? Rc�.ord5 111A Ll I INT 0 RhIl A T 10 N' So' cc of 'A'u sy,,ttrn purnpcci Ls p;,-, in,,Pjdon (yes or no): &,i'l H Yet volume pumped: _12,,giHons .- How was Q061 Pumped determined? TYPE OF SYSTEM soil Ano- ccupooi A ShAd Mm (Yes Or no)(iry, ankh prcybus Mpechon words, Warty) Innoy'"I"MIT" RNMOlogy, Attach i copy Of AC C=crtl op"Won and mainicn&nct contract (to b,- Waked bom SyMyrn nw,r'; i0,1 "- -, t�/i-- A ch,I (OPY of th D E P �pprovn I D�hcr (dcscribc): 4 Pprox WR 2 ec or a H cornponc.1)(5, date in sta!led (if kno"vn) and source or in forma i iow Were scwagc odws dcond Man =mg m the sk (yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address:406 Buckskin Path centprville Owoer: Conrad Johnson Date of Inspection: 10/21 /03 BUILDING SEWER(locate on site plan) Depth below grade: � � Materials ofconstrvction: cast Iron !/40 PVC �'othcr(explain)/'" o zange&e zg /2.ipe. Disunce from private water supply well or suction line: A Y'_ Comments (on condition of joints, venting, evidence of leaka e, etc.): 1o.inth 2 t aRneaight No evidence o7 LIV' age System .i,s Lente&c�tha.ough the tool Uenta. ' SEPTIC TANK: 1�glocat�on sate plan) Depth below grade: // Material of construction: x :concrete4 metal kfiberglass,:�!&olyc hylene o!V0othcr(cxplain)_ ,44� If tank is meal list age: _ Is age confirmed by a Certificate of Compliance (yes or no):d-)4(anach a copy of certificate) J Dimensions: Sludge depth / Distance from top oaf sludge to bonom 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 r baffle: Now were dimensions determined: .��/r a7 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels ,as related to outlet invert, evidence of.leakage, etc.): EPum 3e t.ic tank eueay 2-3 yeazz. In.eet 9 outiet tee.6 ate Dear e—Zhe tank i,3 etauc t uAa y .soure an wno ev,idenee oZ .Peakage L1�qu.id 2eLee at,�-he, oute'et' -inve/tt i.6 57" GREASE TRAP: nglocatc on site plan,) Depth below grade: Material of construction: concrete.,/, metal fiberglass jJ&olyethylene�Zfther (explain): na Dimensions: _na Scum thickness: na Distance from top of scum to top of outlet fee yr baffle: �'na Distance from bottom of$cum to bottom of outlet tee or baffle: na Date of last pumping:na Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structwal integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap not present 7 Page 8 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Add ress406 hnc-kGki n Path �'pnt.Prvill� Owner:Conrad Johnson Date of Inspection: 10/21 /0 3 TIGHT or HOLDING TANK: no (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: na Material of construction: dAconcrete4ymetal w,l fiberglassil/,4polyethylene,&0 other(explain): na Dimensions: na Capacity: na gallons Design Flow: na gallons/day Alarm present(yes or no): na Alarm level:n_ Alarm in working order(yes or no): na Date of last pumping: na Comments(condition of alarm and float switches, etc.): Tight—or Holding tanlc not present DISTRIBUTION BOX: no (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: na 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.): Distribution box is not present. PUMP CHAMBER: no (locate on site plan) Pumps in working order(yes or no): na Alarms in working order(yes or no):Ila_ Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): _ p tlmpr•hamber nnf- nrRgPnt 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 406 Buckskin Path Centerville Owner:Conrad Johnson Date of Inspection: 1 0/21 /03 SOIL ABSORPTION SYSTEM (SAS): Zoocate on site plan,excavation not required) If SAS not located explain why: Located: See recce 10 Type t/ leaching pits, number:L leaching chambers,number: id0 leaching galleries,number:Q AJ61eaching trenches,number, length: leaching fields,number, dimensions: d [9 overflow cesspool, number:CZ �! innovative/altemative system Type/name of technology:7/ tVa Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loam hand to medium eand to ;eine Band. No e-igne o� hydaau.Pic �aiivae oa /londing. Soiie ate day, Vegetat.ion ie noamate. ldaete wci en t.e 24" ge.Pow .the imaea.t /2.i/2e. CESSPOOLS: no (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: na Depth—top of liquid to inlet invert: na Depth of solids layer: na Depth of scum layer: na Dimensions of cesspool: na Materials of construction: na Indication of groundwater inflow(yes or no): na Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ress ool c Arp n11t g1rp$2nt PRIVY: no (locate on site plan) Materials of construction: na Dimensions: na Depth of solids: na Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present.. 9 Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 406 Buckskin Path Centerville Owner: Conrad Johnson Date of Inspection: 10/21 /0-3 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. O I • I p W yob v �� skims /1:7"A�'f/ 10 i Page I I of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C > , SYSTEM INFORMATION (continued). Property Address: 406 Buckskin Path Cantervi 1 1 p Owner; Date of Inspectiott:1 0/21 /03 SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: ND Obtained from system design plans on record - If checked, date of design plan reviewed: NA yf— Observed site(abusing property/observation hole within 150 feet of SAS) NoZ Checked with local Board of Health-explain: N,4 yf_L Checked with local excavators, installers- (aaach documentation) y6S Accessed USGS database-explain:hi_ /:://1-own, ga zn.6 t`agie. ma. u,s. You must describe how you established the higgh round water elevatiqn: zed: Gah2etu 9 �1� 22e2 model. 12116/�I4 G2ound wanes eievat_ionz move zea Pevei. ',sect: US weii data. June 1992 '.'6ed: aSlc • 70rha rrJP O,/.PPP# in 92-000- 1 %.Pa.te #2 Janua.,zy 79Y2 fin-n—u-77— Leaching Pit :cct if Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bosom t of the leaching pit and the adjusted groundwater table is feet. 11 11 /'ITT�AT7TT-11111"J,1I'I.�IITT.1lw�Jw#1•.1_I�fw►!��\AIn�i1 T�1��111-9� •• 1' '1'UNN OF AARi`TCT�RT.F BOARD OF HEALTH ..rn_....•....-T"'_SUIISUNFACF SFN�AQE DISPOSAL ,SYSTEM INNSPECTION FORM - PART D .- CERTIFICATION I -TYPO OR PAINT CLCAALY- P110PERTY INSPECTED STREET ADDRESS 406 Buckskin Path Centerville ASSESSORS MAP, BLOCK AND PARCEL t 192-124 OWNER' s NAME Conrad H. Johnson PART D - CERTIFICATION NAME OF INSPECTORJoseph P.Macomber .Jr. COMPANY NAME J P Macomber & Son Ind. COMPANY ADDRESSBox 66 Centerville Mass . 02632 5tr 9t Town or City Stat• LlP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this nddress and that the information reported is true , accurate , and omplete as of the time of inspection , The inspection was performed and any recomme►Idations regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check o 'e ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 16 - 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of Lhis form , System FAILED* The inspection wllic)l I have con cted has found that the system fails to Protect the j-)ublic health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signaturexmel Date Xnd copy of thiscrtification must be provided to theOWNER, the BUYER here applioable ) and the BOARD OF HSAL'1'11, * If the inspection FAILED, the owner or"' 'Perator shall upgrade ' NaYste ithin one ,year of the date of the inspection , unless allowedorthe requiredm otherwise as provided in 3.10 CFIR 16 , 306 , partd , doc SEWAGE INSPECTIONS LOCATION4Q6 RurkAkimpa.th DATE 70121103 VILLAGE Cente zviiie, (7a-3-s. ASSESSOR'S MAP & LOT 192- 124 -INSPBCTOR �ozeph P. Placomaea a2. SEPTIC TANK CAPACITY _1000 gaiiorzz No Box LEACHING FACILITY: (type) 1-Li-1000 (size) 1500 gaXionz NO. OF BEDROOMS 3 BUILDER OR OWNER H. Conrzad 7ohnzon OWNER MAILING ADDRESS -Same ✓E \ w i y o� ,Q v ck s�i� �'�aTy • F' TOWN OF BARNSTABLE { LOCATION �Y�b ��G a° SEWAGE # VILLAGE ` .e ✓r''f' 'IOW5� ASSESSOR'S MAP.&LOT � INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)� l .�J� '� l�% (size) l NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 1f Separation Distance Between the: t 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 e wetlands xist,, within 360 fee f 1 c • acility Feet x/ Furnished by ` e FrvAl i i � NoGfO 9-- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........OF....../� I1�rs�f ._. ..: 1 ........................ Appliratiun for Di-gVviial Works Towitrnrtion Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .....��d&/.__ ,Sf�s�).../4 .......e!!��_7 ------------------------------------•------......------.............--•......--- .• Location-Address - or Lot No. .. -5... ......----•---•................................ . -----------•................_......_.. .......--•---..............................--- Owner --------------------------------------------Address Installer Address Type of Building// Size Lot............................Sq. feet V Dwelling o. of Bedrooms....... .............................. Attic ( ) Garbage Grinder ( ) '404 Other—T e of Building No. of persons............................ Showers — Cafeteria 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 ( ) 2 Percolation Test Results Performed bY.......................................................................... Date........................................ 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........................ R+ - -------------- O Description of Soil--.... . : •- - nor " "� U Nature of Repairs or Alterations—Answer when applicable.___- -. ....................... -•------•---------------------------------------------•--•-•-------......-----------•-•---•----•----------------------------------------------------•---••••-••-•••••--•-•••--•--•--•••-----......---••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITa 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued I the oard 9f health. Signed �... .. ... .-----•....... ......-fir Date Application Approved BY ----_.--- �1 , ....... .�......... . ?-`.�.. Date Application Disapproved for the following reasons:.............................................................................................................._ -•-----•----•-•--•--•----•--•.................................••...---........---•-------•-•--.........---•-........._..._..--•-----•---•--••--•...--•--•--••------•----•••---•-••••••••--•--•---•------ Date PermitNo........ ? ._. m' ._.l.................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .Je- .........�,?fW,40�.. .....OF.......:. , f ;P�� .-....................... Appliratiun for Disposal Works Tonstrurtiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. ... �t. .. ......- ---........ .........................•- ............................................. -._................................_._..... Owner Address a ... ............................................. ............................................... ............................................... ,. :.... Installer Address d Type of Building,� _ Size Lot............................Sq. feet Dwelling f"No, of Bedrooms._...._-;?..............................Expansion Attic ( ) Garbage Grinder ( ) a� Other—T e of Building No. of persons............................ Showers YP g -------=•----•-•---••---•--- P ( ) — Cafeteria ( ) Otherfixtures -----•--•-------------------------•-•----------•---•----------------•-----------------------••--------•------------------ --------•-- Design Flow......:.....................................gallons per person per day. Total daily flow............................................gallons. W , WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..................... 44 Test Pit No. 2-----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ ._.._..-_. , ........_--•................................. ..... •------------...... -----.............0 Description of Soil__.... y ...... U --•-------------------- _----------- ••----------•--------------____-----••--••--•-----•---------- ---------------•---------------------------------- •--------------------------- -------- -------------------------------------------•------------------------------------•-----•-•-----.....-----•---- -------.......�---•-----------•-- V Nature of Repairs or Alterations—Answer when applicable_--.�:- ._.°-c_, r"..__ Ll ,a .................... ----------------------------•-----..._...-•--•------....---.........------.........._.......-----•--.....--•---.._....._----------------------••-----......-------•---------------------------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until.a Certificate.of Compliance has been issued b the oard f health. Signed_.. 's!, s? +. -1s;', -- fir.... Date Application Approved By._ Date Application Disapproved for the following reasons:..........................................................................................................-__ .........................•-----------•--........----••-•----------...............----._...-•-------.....---•---•-•----........-------------..._...----..__.........------...........---------•........_ _ Date Permit No....---- - s �-� Issued.....------•--• - --•-------•........................ Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH ......... e ...........OF...... yr. 'r G-r`r .+`P Tatif utttr of Tumplittnre T S S T. CERT�Y, That the Individual Sewage Disposal System constructed ( ) or Repaired by--- '�''l" ?`x:� ',.----.....-- ........................ .............. --------- ------------ ---............. -------- ----------- at----- -.-..2?....... . % �._. ---- 1 taller has been installed in accordance with the provisions of TITLE 5 of 5 T �he State Sanitary Code as dribed in the application for Disposal Works Construction Permit No.......�S�_.. . _C__'__ . ..... dated........ ./. .. ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTES THAT THE SYSTEM WILL E C ION SATISFACTORY. ---- DATE.............................. :C............................. Inspector...------ -.......-----•--------------------....-----•------.....----•-----....... THE COMMONWEALTH OF MASSACHUSETTS f/...-. BOARD OF HEALTH Nw.(.............. / ............ � �- ..................... Fa /.�1.�.�..'.it - Disposal or s Tu strurtiun Vamit Permission is hereby anted.. /r .� _ Y ......___.. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo........................................................................... ............. Street G as shown on the application for Disposal Works Construction Permit No.. .:_ C1 Dated.....f_t- p.�.................. Board of Health DATE---------. ................................... FORM 1255 A. M. SULKIN, INC.. BOSTON L.00'ATION SEWAGE PERMIT NO. 12 6 pacl kL t4,A VILlAG`E J r,�t �lF I N S T LLEIt's NAME ter ADDRESS s Il U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z %` �� k 7L(-i \ \ � q5� \ r o\� _. . - . . ... - - -. : - . . . I I- 1. . . 1. 1 -( . . . , : , . 'r' _.. - . ' - " . .. -el I . . ! . 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