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HomeMy WebLinkAbout0065 CAMP OPECHEE ROAD - Health n Camp Opechee 'Road erville P 210 002 SIIII �gECYCLFpC weade IN UPC 12543 No.53LOR o�Aos7,CON5°�� HASTINGS.LIN Commonwealth of Massachusetts Title 5 Official Inspection Form jl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 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 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections _ use the return Company Name key. 52 Rivers End Road r� Company Address Teaticket Ma. 02536 City/Town State Zip Code «� 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I 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 06/08/202 --__._-- In ector'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 I T Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Camp Opechee Rd Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 2 bedroom home has an H-10 1500 gallon septic tank with and H-10 D-Box feeding (2) 500 gallon leaching chambers with stone. At the time of the inspection no visible failure criteria was found. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r ° Commonwealth of Massachusetts �x Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd V' Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 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 c Commonwealth of Massachusetts in Title 5 official Inspection Form �= r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Cam O echee Rd u P P Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that`-protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 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 lI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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 j ❑ ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form 1� r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 65 Camp Opechee Rd v Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 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 ® ❑ 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)] t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c � Commonwealth of Massachusetts �x Title 5 Official Inspection Form ,V Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd v Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 380 GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 years usage d town water Detail: In 2020-50,000 gallons were used and in 2019- 31,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c � Commonwealth of Massachusetts - Title 5 Official Inspection Form — r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 65 Cam O echee Rd v P P Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd L Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): " Depth below grade: 21feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I u— 65 Camp Opechee Rd Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12 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: H-10 1500 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd �V Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form III I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. ;� � 65 Camp Opechee Rd -v Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 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): Depth of liquid level above outlet invert 0" 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �! 65 Camp Opechee Rd u Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V., 65 Camp Opechee Rd Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityrrown 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.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I< .`C 65 Camp Opechee Rd u Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd Property Address Steven Tellegen Owner's Name -v.ry Centerville MA 02632 06/08/2021 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 07 2 ''1 � 1 s -01-,Y'N 5"U, -4 `4; --v 4 r i ry 5 tee: w f 5 E F t , , f :. P r p G r / k r t (-3 4 ' d a I :3 TM 5 Offidd kwscban Fwmr Asmarftm Sys. - �I E d._ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells i 12 plus feet Es timated mated 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 ® 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c � Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 65 Camp Opechee Rd V Property Address Steven Tellegen Owner Owner's Name information is required for every Centerville MA 02632 06/08/2021 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 J COMMON«h LTH OF MALSSACHT SE zi p TTS . EYECI iI`�E OFFICE OF r 7-`L j-i DEPARTMENT OF ENTMOITME-TAT. PRO T E C T T, /V'1 yro a/v oo L o TITLE S OFFICIAL INSPECTION FORII—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE«'AGE DISPOSAL SYSTENT FORM PART A CERTIFICATION ProperryAddress:G /� CGS O �`jeP� RL✓ -/ �`3� ChTerf/ oeea63o? Owner's ct rt v, O«ner's ,Address: SQL.! Date of Inspection: // O Name of Inspector•4(please print) Mee- CompanN dame: Z/Vv/O TAG l 71 Mailing address: 101a >C / C Telephone\Number, SO — CERTIFICATION STATENZENT 1 certify that I have personally inspected the sewage disposal system at this address and t!.at the in e<_;a,ic eua' ' below is true. accurate and complete as of the time of the inspection.The inspection z;as ne�o-net based�s . t a ring and experience in the proper function and maintenance of on site sewage disposal ;yste r_r-; am a Df P approved s-stem inspector pursuant to Sec ' 15.340 of Title 5(310 CMR 15.000). ne _� t^J d Conditionally Passes Needs Further Evaluation by the Local Fails G� e Inspector's Signature: Date: The sv_stem inspector shall_submit a copy of this inspection report to the Anpro<�.g Aut ho - r:`�oa-d o_'lieai h DEP)within within 'DO days of completing this inspection.I:the system is a shared system.or has a de-sign,-sign,i =.y;,; nr;r: -pd or greater, the inspector and the system owner shall submit the report to the app:op ate r?cicnzl of c DEP.The original should be sent to the system owner and copies sent to the buyer, irapp;icabl any _urhority. - - .-- - Notes and Comments YY 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 6/1512000 Pile 1 Page 2 of I OFFICI_AL INSPECTIO FOR'%I—'_\OT FOR VOLti T_AZY ASSESSA EATS SUBSURFACE SEWAGE DISPOSAL SYSTEM I\SPECTION FORM PAfZT A CERTIFICATIO'\ (continued` Property Address: PI o 1,7e e z�-6(� ow ner: i Date of Inspection:. 3 Q Inspection Summary: Check A.B,C.D or E!AL«'AY-S complete all of Section.D A. Svst Passes: V I have not found any information which indicares that anv of the failure cite a described i- 15.31103 or in 3 10 CNIR 15.304 exist.Any failure criteria not evaluated are indicated belo Comments: W7ne em Corditionall- Passes: or more system components as described in the"Condltlonal Pass"'section need"0'?,-rez)! Or repaired. The systern upon completion of the replacement or repair;as approved by the Board of Health. i•:=1i sass. Answer ves_no or not determined(Y,'\'\7D)in the. for the following statements. If"no,dete r nod-',lea—Se explain. The septic tank is metal and over 20 years old-- or the septic tank(-�yhet'ner rre tal or not, is szr-acrura_, unsound, exhibits substantial infiltration or exfiltration or taric failure is i:n-n neat. syste.n-. =11 r•ass LiiS •e._-o- .-__. existing tank is replaced with a comolving septic tank as apwoved by the Board of Health. *A metal septic tank-,till pass inspection if it is structurallv sound.not leaking and if a Ce of cite of Co=lia-_ce indicating that the tank is less than 20 years old is available. ND explain: 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. Svstern-z?il p_ as. :~speaen _~ approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced '—D explain: The system required pumping more than 4 times a year due ro broken or obs`^:uc>ec nip?i s's. -__ pass inspection if(with approval of the Board of Health): broken pipe(s)are reputed obstraction is remoV ed explain: Tiric � toc+�or+inn hn+-ti. �;�:'�nnn � Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR NTOI UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR_1I .PART A CERTIFICATION(contiZued) Property Address: v� �Gi r�'J D FC 4-a, /eG G Zvi �2 302 Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: &/Conditions exist which require further eval_uaron by the Board of Health in order o deter--,-e i=_~e s_;-s em is failing to protect public health. safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 C--,-IR 1_^-.303M(b) that the system is not functioning in a manner which rill protect public health, safety and the environment: Cesspool or privy is withi_*i 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated:wetland or a salt marsh ?. Svsterri 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 euNgronment: _ The system has a septic tank and soil_absorption system(SAS) and the SAS is -thin 100 et of a surface water supply or tributary to a surface eater supply. _ The system has a septic tank and SAS and the SAS is within a Zone i ofa public The system has a septic tank and SAS and the SAS is within 50 f et of a n- at:z-ater su n� v e'i. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fier or more mom a private water supply-v ell". Method used to determine distance "This system passes if the well water analysis.performed at a DEP ce.L-ifed laboratc_ fo_- cell o= bacteria and volatile organic compounds indicates that the well is free from pollu_ion=oM that tzcili an the presence of arrrnonia nitrogen and nitrate nitrogen is equal to or less than 5 pptn.prc%-ided t.a-no o ,e- failure criteria are triggered.A copy of the analysis must be attached to this four?. 3. Other: Page 4 of i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLU T_-kRY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: C��^J ,o,P G ,i ee Owner: Date of Inspect on: fl, D. System Failure Criteria applicable to all systems: You must indicate " es" or"no"to each ori the following for for all inspections Yes No _ ackup of sev.aae into facility or system component due to overloaded or clogged SASS orc.�;poo ! 9iDischarge or pondina of effluent to the surface of the ground or surface water_ dine to a- o ,cogged SAS or cesspool y t—/ Static liquid level in the distribution box above outlet im ert due to an overloaded cr c;cz.eo�_I o' cesspool _ Liquid depth in cesspool is less than 6"below-invert or available volurne is less than ' day 1�Required pumping more than 4 times in the last year NOT due to clogged or obstructed pi__e(,s'. of times pumped f/�nv portion of the SAS.cesspool or privy is below 1-72h_-round water elevaron. v fin 'portion of cesspool or privy is within 1010 feet of a surface wafer supply or i._J-L:a":.o a Ziu-faCc �rater suppiv. Any portion_of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply-:.k-.11. �/ .Any portion of a cesspool or privy is less than 100 feet but--eater than 50 feet from a private�N7ate: supply well with no acceptable water quality analysis. [This system passes if the well water anal-,-sis. performed at a DEP certified laboratory.for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the Dresence of ammonia nitrogen and nitrate nitrogen is equal to or less than;ppm,provided that no other failure criteria ,�/,�J are triggered.A coPy of the analysis must be attached to this form.] /V l/ (Y"es/\c) The system fails.i have determned that one or more of the ago e failure cr_er: exist as described in 310 CMR 15.303,therefore the system fails.The system ovvner should contact th.Bcard o= 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 floe; of 10.000 cpd to 1-4.000 apd You must indicate either"�-es".or"no"to each of the fbflfc virg: (The following criteria apply to large systems in addition to the criteria above) v s the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinklne water su.r, the system is located in a nitrogen sensitive area(interim Wellhead Protec-Lion_A-ea-7j. D. Zone II of a public water supply well if you have answered"yes"to any question in Section E the system is considered a sigi=cant _- yes"in Section D above the large system has failed.The owner or operator of any large :vsa ccn_ de_: si,rificant threat under Section E or failed under Section D shall ozr u _jade the s�glom s a c r_an. e ; - _5.304. The system owner should contact the approp Jiga rp.e2;enaI office of the Departme_r,;. •T;c'.o C fncnorr;n., ��„.•. ��1:»nun 1 Pase 5 of 11 OFFICIAL I\SPECTIO\rFORti1—NOTFORVOLUNT_-RY ASSESS IIENTS SUBSURFACE SE`VAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ( Gi O eG42Pi /� � ✓v� � Oa�63,L Owner: Bate of Inspection: Check if the followins have been done.You must indicate"yes"or"no"as to each of the follo%Lin_: "c O 'H Pumping information was provided by the owner,occupant, or Board f ealrh � v `Z%ere any of the system components pumped out in the previous two'weeks Has the system received normal flows in the previous two week period 2 v Have lar 2e volumes of,.rater been introduced to the system recently or as pa_t of in-is were as built plans of the system obtained and examined?(If rev were not available rote as Was the facility or dwelling inspected for signs of sewage back up ✓ Was fire site inspected for signs of break out 1 Were all system components.excluding the SAS,located on site Were the septic tank manholes uncovered. opened. and the interior of the tark inspec:e fo-_h of the baffles or tees. material of construction;dimensions. depth of liquid. depth of sludge arc depth of scum V-as the facility ovTer(and occupants if different from owner)provided'=k th iL=orma o.~on.he prcre- maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been det,1 =ned based on: Yes no v 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 a^--c;�= -`r c= is unacceptable) f310 CMR 15.302(3)(b)j f Page 6 of 11 OFFICIAL INSPECTION FORAI—'NOT FOR VOLUNTA-RY_ SSE c S-;-E\TS SUBSURFACE SEWAGE DISPOSAL SYSTFNI fNSPECTTON FORM PART C SYSTEM UNTORAIATIO Property Address: lJ� Cam'wl O GAG �tL Owner: Date of Inspection: // ? LO`V CO\TIITIONS �JPrPW t� RESIDE\TI_AL n \umber of bedrooms(design): Number of bedrooms(actual): c2. DESIGN floes based on I0 C 15.20 (for example: 110 gpd x-of bedroo s): J70 \umber. of current residents: Does residence have a garbage grinder(yes or no): is laundry on a separate sewage system{ves or separate inspecr_on required; Laundry system inspected(yes or no):_� Seasonal use: (yes or no): /VO water meter readings, if available(last 2 years usage(apd)): Sump pump (Yes or no): / Las;date of occupancy: r/P✓r� CO-AnIERCIALL/1-ND STRI_L Type of establishment: Design tZow(based on 310 CNIR 15.2.03): gp•d Basis of design flow(seats. persons/sgft,etc.): Grease trap present(yes or no): industrial:waste'holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(,yes or no):_ Vvater meter readings. if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pump' ng Records Source of information: Was syste_n pumped as part of the inspection-Yes or no):/�� If ves; volume pumped:_gall ons--How was quantity pumped determined? Reason for pumping: TY V`OF SYSTEM _ p is tank, distribution box, soil absorption system _Single cesspool Overf:ow cesspool Privy Shared system(yes or no) (if yes.attach previous inspection records,if ant) innovative Alternative technology. Attach a copy of the current operation and Obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components; date installed(if?ono n)and source of lfo naron: 0?000 «'ere se«age odors detected�.vhen arriving at the site(:'es or no):ll*",e Dag- of i i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS_�iENT1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1T PART C SYSTEM INFORNLATION(continued) Property Address: t0� �G � o ��e�►2 �� Owner: le Date of Inspection: 0__6 BUILDING SE«T-R(locate on site plan) Depth below wade: Materials of construction: i__oe��iron � PV C_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting,evidence of leakage,etc:): SEPTIC TANK:_(locate on site plan) Depth below grade: 1 Material of consn action:_concrete_metal_fiberglass__polvetht_-tene _o icer(expl ain) Tf tank is metal !is-age:_ is age confirmed by a Certificate of Compliance(yes or r_oj: _ i a-ac`a CO—. o certificate; Dimensions: (> Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: g_ Scan thickness: Less Distance from top of scum to top of outlet tee or baffle: 4o Distance from bottom of scum to bottom of outlet tee or baffle: / Ho'\ were dimensions determined: /'o le �a o/e v/4 Comments (on pumping recommendations,inlet and outlet e or baffle condition. s-^ac ral i te?:i?. lia_u C' e:ei as r lated to outlet invert, evidence of leakage eV: TG&,ly- ! µ d 74-,e s /0' 1 G?Ob_C Ovi ips7, (� ea cvf GREASE TRAP: _(locate on site plan) Depth below grade Maierial of consma,ction:_concrete_metal_fiberglass (explain): _ Dimensions: Scum thick-^_ess: Distance from ton 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: Comments (on pumping recommendations. inlet and outlet tee or baffle condition, s m u: ,; I —. as as related to outlet invert, evidence of leakage,etc.): Page S of 11 OFFICIAL INSPECTIO\FOR I—NOT FOR VOLUNT'_ARY ASSESS-IE T S SUBSURFACE SE«'AGE DISPOSE SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property-Address: v� 0"1 pP�2Gh2P �� d► "e✓� /�l/� Oat� 3� Otsner: �� Date of Inspection: // 3 TIGHT or HOLDING TANK:�/ (tank must be pumped at time of inspection)(iocat: on site lam) Depth below grade: _Material of construction: concrete metal fiberglass_pol-ethylene others;exrlai-': Dimensions: Capacity: gallons De.sigr.Flo%v: gallons/day- Alarm present(yes or no): y Alarm level: ".farm in working order(ves or no): Date of last pumping: Comments(condition of alarm:and float switches,etc.): DISTRIBUTIO'_1'BOX: �afplesent must be opened)(locate on site plan) Depth of liquid level above outlet invert: L- Comments (note if box is level and distribution to outlets equal,any-evidence of solids carr.-ovtr. ant,eviv=nce of leakage int•o�rout of box_ tc.): �EyQ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber; condition ofpumps and appurtenan--e_. Titl. Tt1CTlP/tt(lr� �nrm �'1 %^,Mn , Paae 9 of 11 OFFICIAL I'_NSPECTION FORM—NOT FORVOLL-lTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORNIATION(continued) Property-Address: CG o 0-;vner• l� Date of inspection: SOIL ABSORPTION, SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: o o e 4.7 pv leaching chambers.number: leaching galleries, number: �/ �1_ e leaching trenches. number, length: r7J leaching fields,number_ dimensions: o-°erflow cesspool, number: ire ovativelalterr:ative system P, elname of technology: Comnier_ts(note condition of soil; signs of hvdrauiic failure,level of pending; damp soil. condition or veg—a't= 'I l!n G1 // eOl-e, CESSPOOLS: /// (cesspool must be pumped as part of inspection)(locate on site plar_; \urnbe:and con quration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments mote condition of soil. signs ofhydraulic failure,level of pondin2. condition cf egeTa ian. a:.`: PRIN,-Y: locate on site plan) Materials of construction: Dimensions: . Depth of solids: Comments (note condition of soil, signs of hydraulic failure,level ofpondinQ. condition 0-- 9 Page 10 of 11 OFFICIAL. _!. SPECTIO>\ FOR'NI-NOT FOR VOLUNTARY ASSESCME1TS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART IC SYSTEM INFORMATION(continued) Property Address: P U G e? O eG122e /2 Date of Inspection: Q SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sexyaoe disposal system including ties to at least M-o permanent reference land nark_ o- benchmarks. Locate all wells -,l°ithin 100 feet.Locate-where public water supply enters the builcin o. 1. d3"4 fy�_ a 9 a 3 4- 31 eq- 22 L An:rnnnn 0 Pane 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS'N-TENTS SUBSURFACE SE""AGE DISPOSAL SYSTEM INSPECTION FORM r_A-xT c . SYSTEM INTOR LATIO (continued) cr Property-Address: �''`� 0 P c Ors-n er' Date of Inspection: 1 SITE Ell Slope Surface water Check cellar Shallo-v«-ells I0� C p/ Estimated depth to around«-ater � feet Please indicate (check) all methods used to determine the high ground eater elevation.: Obtain om system design plans on record-if checked,date of design plan rep e.j ed: O' e ved site (abutting property/observation hole thin 150 feet of SAS) Checked with local Board of Health-explain: Checked«vith local exca-vators. installers-(attach documentation) Accessed USGS database-explain: You must describe hot;,you established the high ground water elevation: Cr/O a vi L Lo c //0 H s o.?(. �u e COMMONWEALTH OF MASSACHUSETTS in EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP 2-I o PARCEL, ,--C LOT � TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 65 Camp Opeechee Road,Centerville,MA 02632 Owner's Name:Jennifer&Jeffrey Morassi RECEIVED Owner's Address 65 Camp Opeechee Road,Centerville,MA 02632 APR 0 9 2004 Date of Inspection: March 26,2004 Name of Inspector: REID C.ELLIS TOWN OF BARNSTABLE Company Name: ELLIS BROTHERS CONST.CO. HEALTH DEPT. Mailing Address: 23 ENTERPRISE ROAD, P.O.BOX 59,YARMOUTH PORT,MA 02675 Telephone Number: 508-362-6237 CERTIFICATION STATEMENT 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 fimction and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuan7pa.7ss.es on 15.340 of Title 5(310 CMR 15.000} The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: G Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health* 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. _ 1 Page;2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 Inspection Summary: Check A,B,C,D or E/AkWAyS complete all of Section D A. System Passes: -12 I have not four 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 pass": 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 replacet ient 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`Snot 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 exfiltratioi 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 struM rally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ava le. ND explain: obstructed pipe(s)or due to a broken,settl Observation of sewage backup of break out or igh static water level in the distribution box due to broken or ed or unevei i distribution box System will approval of Board of Health): Pass inspection if(with broken pipe(s)art replaced obstruction is ren oved distribution box i leveled or replaced ND explain: The system required pumping more than 4 timt s a year due to broken or obstructed pipe(s).The system will Pass inspection if(with approval of the Board of Heal ): broken pipe(s)are j eplaced Obstruction is remo ved ND explain: 2 i Al\1 L'1 CERTIFICATION(continued) Property Address:65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 /� C. Further Evaluation is Required by the Boa rd f Health: Conditions exist which'require further evaluat on by the Board of Health in order to determine if the system Is failing to protect public health,safety or the enviroi iment. 1. System will pass unless Board of Health de rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner whit i will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a si w&ce water Cesspool or privy is widen 50 feet of a dering vegetated wetland or a salt marsh 2. System will fail unless the Board of Hft" ad 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 abs Mption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface i vater supply. The system has a septic tank and SAS an the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS an I the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS an I the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to etermine distance **This system passes if the well water analysi ,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indi es that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate itrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the ang lysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jenifer&Jeffrey Morami Date of Inspection:March 26,2004 D. System Failure Criteria applicable to all systems: You must indicate`Yes"or`no"to each of the following for all inspections: Yes of sewage into facility or system component due to overloaded or clogged SAS or cesspool �YPhischarge 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 — ,1�cesspool Xuid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface supply. y portion of a cesspool or privy is within a Zone 1 of a public well. 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 coliform bacteria and volatile organic compounds indicates that the well is free 8rom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failare criteria J are triggered.A copy of the analysis most be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system most rve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the ollowing: (The following criteria apply to large systems in addition to the criteria above) yes no — the system is within 400 feet of a surface dr,nking 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 krea(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. 4 Page 5;of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Y No ping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _ — las 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 in _ spected for signs of break out? _ Were all system components,iN y ponents,eiccluding the SAS,located on site? V Were the septic tank manholes uncovered,o and the interior opened, error of the tank inspected for the condition of the ffles 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: Yet/ no Existing information.For example,a plan at the Board of Health. Determined in the field(if an of the failure is unacceptable)[310 CMR 15.302(3)(b)]y �related to Part Cis at issue approximation of distance 5 i Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:65 Camp Opeechee Road,Cenierville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): �- DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .� Number of current residents: 2- Does residence have a garbage grinder(yes or no): A10 Is laundry on a separate sewage system(ye or no)/V Laundry system inspected(yes or no): 0[if yes separate inspection requited] Seasonal use:(yes or no):-4u p Water meter readings,if avail ble(last 2 years usage(gpd)): 3 Sump pump(yes or no): 0 Last date of occupancy: COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203), gpd Basis of design flow(seats/persons/sgftetc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or n Water meter readings,if available: Last date of occupancyluse: OTHER(describe): �-- GENERAL INFORMATION Pumping Records r Source of information: �� � �� 13'D �!� l�lj �',�,�,lce. /V Was system pumped as part of the inspection(yes or no): ✓ . If yes;volume pumped:/ADD gallons—How was quant' p mped determined? ,Q Reason for pumping: 'I Y 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) _InnovativetAhernative technology.Attach a copy of the currant operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age all components,date' stalled(if known)and source of information: — i-� Cam--7e7l-a Were sewage odors detected when arriving at the site(yes or no):A/Q 6 TOWN OF BARNSTABLE LOCATION v S 04 M-P O PCc C tF65 /ZIP SEWAGE # --j s VII.LAGE C E,uT -V!1'L'� ASSESSOR'S MAP &LOT i INSTALLER'S NAME&PHONE NO. c.��S SEPTIC TANK CAPACTTY LEACHING FACILITY: (type) �j (size) I oZ`jZ. �ZS `� l NO.OF BEDROOMS �— BUILDER OR OWNER V PERMTTDATE: I - COMPLIANCE DATE: 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 I within 300 feet of leaching facility) Feet Furnished byis il , Z-Z _ Z _ sn-0M ±0 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART C SYSTEM INFORMATION(continued) Property Address:65 Camp Opeechee Road,Cnterville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 BUILDING SEWER.(locate on site plan) Depth below grade:� / Materiahkof construction: cast iron �/40 PVC other(explain): Distancaom private water supply well or suction line: lao 4- Comments(on condition of joints,venting,evidence of leakage,etc.): ; }1�t W-e- cQ. .L A rL, ve-Al-F SEPTIC TANK:J locate on site plan) a Depth below grade: Material of construction: concrete metal fiberglass_polyethylene _other(explain) 1V`If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) ' i Dimensions: L U k 'c 14 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of o} let tee.or baffle: How were dimensions determined- Comments(on pumping recommendkions,inlet anftout t tee bdi le condition,structural integrity,liquid levbis as ref ted to outlet invert,evidence of leakage,etc.): N2 4- O Y fto CT GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal—fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffl Distance from bottom of scum to bottom of outlet tee Dr baffle: Date of last pumping: Comments(on pumping recommendations,inlet and utlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of]l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 ^/ /• A TIGHT or HOLDING TANK: (tank must be pi mped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: —lions Design Flow: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or, o): Date of last pumping: Comments(condition of alarm and float switches,etc. DISTRIBUTION BOX:V,(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: //y 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, c.): / ' I PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition f pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type leaching pits,number: leaching chambers,number: 7141110V 01Z�j � leaching galleries,number: / — leaching trenches,number,length: � �, � / , leaching fields,number,dimensions: �(.0 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.): CZA pZ Al V1 UdA, 'to- "tcjorspectionXiocate CESSPOOLS: (cesspool must be pumped as part 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 or no): 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 fail e,level of ponding,condition of vegetation,etc.): 9 i Page 10 of 11 r" OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:65 Camp Opeechee Road,Centerville,MA 02632 X/ S Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permmem rcfer�cc landmarlw or benchmarks.Locate all wells within I00 feet.Locate where public water supply enters the building. ( C4' j-1 N , 40 3 3l 10 �-�- .`�, 33 Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR SUBSURFACE SEWAGE POSAL SYSTEM INSPECT ON FORMS PART C SYSTEM INFORMATION(continued) Property Address: 65 Camp Opeechee Road,Centerville,MA 02632 Owner:Jennifer&Jeffrey Morassi Date of Inspection:March 26,2004 SITE EXAM Slope Surface water •t/V N,-- Check cellar Shallow wells i Estimated depth to ground waterc;2-'t. ?eet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ecked with local Board of Health-explain: hecked with local excavators,installers- h documentation) c Acessed USGS database-explain: (S/C�� � � "04— You must describe how you established the high ground water elevation: s✓ 4u tA // .3 I1 No. Fee 'We THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Mie;pozar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No Owner's Name,Address and Tel. o. 'OE�fe 2 Assessor's Map/Parcel Z b _ 06 2- dL i ,A-A Installer's dress,a�el� ��P��'�7 Designer's Name,Address and Tel.No. I© I �'C-� 007 i Type of Building: Dwelling No.of Bedrooms C73 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ! Type of S.A.S. Description of Soil 7-0 Nature of Repairs or Alterat)'�s(Ans when applicableQ r� � �f ro &o>e 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,pf the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b and of Health. Signed Date Application Approved by Date Z/ '7Omo Application Disapproved for the following reasons Permit No. Z'GT,0 `7 Y Z— Date Issued l z- ./4/—0-0 No. ~CNyy — 7 Z Fee y e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for ]h6pool *p5tem (Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot N4 5 O�eAch« Owner's Name,Address and Tel.No. - Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 362 " i,2 � '� Designer's Name,Address and Tel.No. ��� 9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank "� Type of S.A.S. Description of Soil 77 Nature of Repairs or Alterations(Ans>ver when applicable)---""r1'S i ,�. ` '� ��`�'' f S /� 7 V. • r ell_ S Date last inspected: ,e 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 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued byhts Board of Health. dyL� Signed z%� L' Dat Application Approved by Date Application Disapproved for the following reaso s Permit No. Z Gjy 7 Z Date Issued 17 4`00 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTT that the Q Ai-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at has been cons"cled in accordance with the provisions of Title 5 and the for Dis osal Sy tem Construction Permit No.�� ' ' dated Zoe Installer ,L"�G .1 v s A-1 7 Designer The issuance of this(pe t s !�l not ., construed as a guarantee that the system will fuu ction V designed Date fA J t Inspector /t./� No! �� 7�'�- ------------------ Fee ' THE COMMONWEALTH OF MASSACHUSETTS Z !U _CJ0 .Z_ PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSES ' - - Migpooaf *pgtem (Con0tructton 30ermit Permission is hereby granted-to Con ct( )Repair( )Upgrade( )Abandon System located at r �. �r/.fie.--- 12N and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to I, comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pe t. - Date: L/�y/�V Approved by Z�, 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS.CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposalworks, construction permit signed by me dated ��' �'� s , concenun the .. ., '4 property located at the following criteria: j . i$V,• This failed system is connected to a residential dwelling only. There are no co mmercial ommercial or business uses associated with the dwelling. V• The soil is classified as CLASS I and the 0.percolation p rate is less than or equal to 5 minutes per inch. i • There arp no wetlands within 100 feet of the proposed septic system There are no private wells-within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �• 'if-the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed "leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) C� B) G.W.Elevation © +the MAX. High G.W.Adjustment T J DIFFERENCE BE;Tr A and B 3 SIGNED: DATE: (Please Sketc proposed plan of system on back]. NOTICE Laddounpaolbedrooms n the above information,a repair permit will be issued for bedrooms maximum. No are authorized in the future without engineered septic system plans. q:health folder:cert '� � `' 1 �. - . . . �t. .�� • � � �� �.' .. �'_,. 4. 4 m`.'.d K n.. _ ,y n L� ---._._ a � � P, , . �. : � � - `�. �, C `�� .:� - .. �V' �� _ . , , . . _ F . �, 4 ,,��` - . -- TOWN OF BARNSTABLE� LOCATION : % G`j "y'- O` h-e�e cA 6-to 'd AGE# l n 5/h'c'6 Z47 VILLAGE C -01 1--'C-r Vt ASSESSOR'S MAP& LOT ( GCJX INSTALLER'S NAME&PHONE-NO. ,a C l%►1 SEPTIC TANK CAPACITY IS' LEACHING FACILITY: (type) 5co C tl_ (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: — COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 13 IV YII v r y 3 r. TOWN OF BARNSTABLE C LOCATION 6S CAM-Po P��CItFE�� � - SEWAGE # -74 VILLAGE Q6:42T GY- O u-.F ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY � � © -CtM� LEACHING FACILITY: (type) �- � 4&5(size) `OZ � aS� `� NO.OF BEDROOMS BUILDER OR OWNER I V PERMIT'DATE: I — '®© COMPLIANCE DATE: 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 leaching facility) Feet Furnished by C'i�l M P O RLJ1� - i r - 2 3-7 P 13 13 - 3 _ 33 ,$ No................ -�-- Fps.. ' ........ THE COMMONWEALTH.OF MASSACHUSETTS -'� BOARD ALTI--� ....----.OF....... ---- ------- --------------------.................. Applirativit for 11ispnsttl Marks Tonstrnrtinn ramit Application is hereby made for a Permit to Construct (�f ) or Repair (Vj' an Individual Sewage Disposal System at ' . ........ .................-................................................................................. 41a. ..A," lzag:�rpl ' c tion-A d1s Q 1 Ilz1 e............................................. Address ...............:/ ... -^ Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria Pa Other fixtures d . ------------------- -------------------•---•.......----•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter...----......... Depth........... x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area------------.-------sq. ft. 3 Seepage Pit No--------------------- Diameter..........-----.---. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results, Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.---.................--. (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----------•------•--•----•••-----------------••----------------......_._..------•----•--...----•--•----••--••---...---........------......••----.....-----•-- 0 Description of Soil........................................................................................................................................................................ x c., •-•••••------------------------•-------...---------••------------------------------•••...----••----•-•--...••--------------------------------•-...---------------------------------.......-------------- x ----••-----•----------=-----------------•--•------••••-••--•------•----•••-•----•-•---------------•----•---•------------- ----------- ------------ - U Nature of Repairs or Alterations—Answer when applicable.&A--- ---.---- lo... _................................ . ------------------------------------------•-------------•--•-------------------•---------------•--•- ..................................................... ............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue y the board of health. Signed-• !! ..................... � Date ApplicationApproved By.................................................................................................... Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------------------•--•- -•------------------------•--•---..........--•-------------.............---------.•..........--------•-•-•---•-------•-------•-----•••-•------•••--------...........---------••-------------••---...... Date PermitNo......................................................... Issued.-• f .........------- -------------- Date ®R-dX7 ,�'` . No.. ..........._..---.. FRs..,,,1.--....»............ THE COMMONWEALTH OF MASSACHUSETTS BOARD F : A TH ._ _ r ...........OF....... .... ................................... Appliration for Dislimal Worko Tonotrurtiun ramit Application is hereby madejor a Permit to Construct ( ) or Repair (kjooan Individual Sewage Disposal System at ........t�...... ?x.; ' 'e._... ....................:.........................................................4._.......___...-- /jr n-Aid " o �tpNo. L.. .. by ..._ .......... ..........._....................`.. . ... `--_X"_: . 10............................................. Y r Address ......... ......... .................................................... ............... ...........------------•-•------- Installer Address g Sq. feet Type of Building Size Lot___________________________ �. V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------•--------------------------------------------------•-------------------••......•---...--•--•----------............._.. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid ca.pacity.._..__..._.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..................... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------- . - ------------------- -----------------------------------------------------------------------••------ DDescription of Soil........................................................................................................................................................................ ; x U ............................. -•----------------.........-••-•-•••..._...-•---------------....._----- --- --------••-• - W ----------------------------------•---------------------------------------------•----•------------- 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 TIT TIE. 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—by the board of health. Signed-_ N'' '"`_... "`' ✓ Date ApplicationApproved BY.................................................................................................. Date Application Disapproved for the following reasons:........................................................................ ` --••.............................•-----------------•-------------------......---------•--....-------•--------------------------•--•--•----•-----•--------------•----------------------------•-...._..__ Date r PermitNo...............................-.......................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH .4.. ........OF........ ... .......................................... T ifiratr of Toutplianrr THIV T`O/ ER F That th Individual Sewage Disposal System constructed ( ) or Repaired . by........t3�.......... ... .. .............. Inst has been installed in accordance with the provision of TI j of The State Sanitary Code as/de crAe2}in the application for Disposal Works Construction Permit No. .. '_�:�. .____. dated __..__ .. ............................ THE ISSUANCE OF.THIS CER IFICATE.SHALL NOT BE CONST ® AS UARANTEE THAT THE SYSTEM WILL FU CTION SAT[ P CTORY s DATE.... ✓ Inspector t F �. ,�" 9iF�, � Ypp � .a r y - ,4S' •u 'ir�r`!''[[M �ri'i'�eYc K��. �t�r��t+r'Mk9G°� ., M,�; ,^r ..,.�.�.. sey:.:.ti!.ran:itw, i mot: ,. _ - je�;', ,t r pa• dm Hr �+itti,�.', �i' i w.,....wG � � THE COMMONWEALTH OF MASSACHUSETTS ':vr BOARD O HEALT No...............7..L.. ........... :. . ..........OF......... .................• ......... ......... � FEE. .................. trrt' rrmit Permis ion is hereby grante =:_. -� _.--4--- ...______._.•. --• _ ___•._ ---- - .. to Const t ( ) or R r ( y an,I ividual Sev�,aa�e D• sal S tem .y T ... ' s et / as shown on t application for Disposal ���orks.Construction Pe It o... at /- - -.-.--..- ....._ ..._ ._ ......................... ........ .....� ..... .. ------------- Board of ealt� FORM 1255 1O BBS & WARREN. INC.. PUBLISHERS - - s x cy\ cp� 'LOCATION SEWAGE PERMIT NO. G�C'i4 mp VILLAGE INSTALLER'S NAME i ADDRESS U I L 0 E R OR OWNER r DATE PERMIT ISSUED n - DATE COMPLIANCE ISSUED �► ' ���. ��� �uS� 2Q` �3. ' 6 �'S'_ , ��9