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HomeMy WebLinkAbout0151 CAP'N LIJAH'S ROAD - Health 151 C,ap'n -Lijah's Road CenteNiie P A = 192 169 1521/3 ORA 10% P2 f Commonwealth of Massachusetts Title 5 Official Inspection Form I %M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 151 Cap'n Lijah's Rd Property Address NO Tim &Anne Marie Brownew Owner Owner's Name information is c required for every Centerville ✓ MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection rxj 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. Inspector Information S'/ (:Su OLI 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 S 13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty 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 10-16-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 . 10-16-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass"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 ON ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r , -'Pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �i :. tF > 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 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 pipes) are replaced ❑ Y ON ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 3 Title 5 official Inspection Form ICI' bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town 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) stem S Failure Criteria Applicable to All S Y pp stems:Y 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 ;w Title 5 Official Inspection Form il Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r " 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions,in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts y Title 5 Official Inspection Form } � I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Cap'n Lijah's Rd J Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 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? ® ❑ Wasthe 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.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts f� ,l Title 5 Official Inspection Form I61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments vJN r I 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2018 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Capin Li'ah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town 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: Owner--pumped 1-2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r , 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 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: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"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.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts T Title 5 Official Inspection Form ! p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 16"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 Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" • Scum thickness lit 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 15" - 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. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' i'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a r ,. :. ? 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ 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 Title 5 Official Inspection Form i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY Property Address Tim &Anne Marie Browne Owner Owner's Name information is 02632 - - required for every Centerville MA 10 16 18 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.): Good condition with water at working level and no sign of back-up from pits. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :_,J_ ?` 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: 2-1000 gal ❑ leaching chambers number: ❑ 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 c Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits in good condition with pit 5 empty at inspection and stain line at 16" off bottom of pit. 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 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments {N 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ; r�- Title 5 Official Inspection Form WD Ii• � 1,61 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A�3 jq t x - - + -4-S t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts P., Title 5 Official Inspection Form 1�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W 151 Cap'n Lijah's Rd Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 c Commonwealth of Massachusetts r� Title 5 Official Inspection Form iil Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Cap'n Lijah's Rd J Property Address Tim &Anne Marie Browne Owner Owner's Name information is required for every Centerville MA 02632 10-16-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I� _ Commonwealth of Massachusetts 1/ 2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments M 151 Captain Lijahs Road Property Address P Y Shea Owner Owner's me 1 information is ' required for every Bar able MA 02632 10/20/2015 z: page. City own 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, S� 4* f 1 27 3 use only the tab 1. Inspector: key to move your cursor-do not A.Riker use the return Name of Inspector key. R.L.C. �y Company Name PO Box 726 Company Address South Yarmouth MA 02664 CitytTown State Zip Code 5087766460 S14590 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 Approving.Authority 10/20/2015 Insp rs 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. �OG� VS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Li a hs Road P 1 Property Address p Y Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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 indicated below. Comments: Inspection of septic tank,distribution box and two leach pits connected in series did not exhibit any obvious indications of failure at time of inspection. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts T W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 17 .1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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 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•3113 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 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 page. City/Town State Zip Code Date of inspection B. Certification (cont.) Yes No i ❑ ® 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. An portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® YP P P Y ❑ ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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. ® EJ 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 GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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)): 2013= 2014= Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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 Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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: Water Pollution Control of Barnstable Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: not required 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 tm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed in 12/14/2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): interior pipes were dry and free of staining Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'x5'x8'6" Sludge depth: 8° t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 page. City/Town 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 Concrete Baffle/26" Scum thickness 3" 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 12" 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.): Inlet tee was missing/was replaced , water level and inverts correct heights observed. 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 scum of to to of outlet tee or baffle P 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 M 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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•3/13 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 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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 equal to single 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.): riser installed at time of inspection . Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Two leach pits piped in series/#1 pit had 12"standing water and pit#2 was dry with stain line>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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t N, Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10 /2015 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 Kew Fron4— fr iSe-- t • �,/mep I 1 3 p1, i �z 11�� l3 C= t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��M z 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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: >12feet 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: abutting test holes ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Topo map indicated area > 15 above G.W. You must describe how you established the high ground water elevation: Plans on file from abutting properties and topo maps of.area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 °M 151 Captain Lijahs Road Property Address Shea Owner Owner's Name information is required for every Barnstable MA 02632 10/20/2015 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 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 2""l "Yl d DEPARTMENT OF ENVIRONMENTAL—PR TECTICTj- s� RCEL. �r 9 !. 0 2005 LwFES N ASTABLE HEA. H DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 151 Capt. Lijah's Road Fri Centerville MA 02632 - Owner's Name: Kimball Owner's Address: Same Date of Inspection: December 14,2004 Job#04-392 K Name of Inspector: PATRICK M. O'CONNELL c� Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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 m training and experience in the proper function and maintenance of on site sewage disposal systems. I am, � F►/// ���' approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste ��� ��......M _X_ Passes =�:. . G Conditionally Passes P TRI ;R, Needs Further Evaluation by the Local Approving Authority = '- Fails 0 L :co Inspector's Signature: Date: 12/14/04 i��FS�j ///nmI 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. Notes and Comments: Overflow leaching pit empty with no sidewall stains.Tank has been pumped every two years and not in need of pumping at this time. ****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 Title 5 Inspection Form 6/15/2000 page I Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: 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. Answer yes,no or not determined(Y,N,ND) in the 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. 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. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Titles G Tncnartinn Rnrm Oil cnnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 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(I)(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 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 coliform bacteria and volatile organic compounds indicates that the well is free from 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 failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title+ G Tr1CrP!tinn Fnrm All V10on 3 i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No —X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _, —X— Liquid depth in cesspool is less than 6" below invert or available volume is less than ''/z day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped —X_ Any portion of the SAS, cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. —X— Any portion of a cesspool or privy is within 50 feet of a private water supply well. — _X— 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 from 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 failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(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 must serve 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 following: (The following criteria apply to large systems in addition to the criteria above) 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. T41. C in —f,'nn Tlnrm 4/1 4 I Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks _X_ _ Has the system received normal flows in the previous two week period ? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X_ _ 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: Yes no _X_ _ Existing information. For example, a plan at the Board of Health. _X_ _ 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(3)(b)J Ti41A S Tncnorhinn Rnrm 411;i11)00 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2002- 15,000 gal.2003—22,000 gal.=50 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Tank pumped every two years. Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_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) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date for overflow pit: 6/28/88 Were sewage odors detected when arriving at the site(yes or no): No Titles S inenartinn 17nrm 411 Cnnnn 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 20' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) ' Depth below grade: 1' Material of construction:_X_concrete_metal fiberglass_polyethylene —other(explain) — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8.5' long x 5.2' wide—1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): this time Liquid level at bottom of outlet invert baffles are intact and clear. Tank not in need of aumying at GREASE TRAP: No (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 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,structural integrity, liquid levels as related to outlet invert,evidence'of leakage, etc.): T41.9 1-0n ,t;nn 17nrm 4i1,�iJnnn 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 Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No solids or high stains,box set level PUMP CHAMBER: No (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 of pumps and appurtenances,etc.): Titles 17nrm All i0nnn 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_Leaching pits,number: Two 6x6 pits in series. 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.): Overflow pit empty with no sidewall stains Pit is H-20 load rated cover is not and should not be driven over. CESSPOOLS: No (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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): T41P S Tne—otinn Rnrm g/1 cijnnn 9 Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 Capt. Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 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. Capt. Lijah's Road 22 Water Service 54 44 26 41 17 28 44 51511 Titles C incnuntinn Fnrm 4/1'�i'nnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 151 Capt.Lijah's Road,Centerville Owner: Kimball Date of Inspection: December 14,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water : More than 20eet 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) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Topo map shows property at or above el. 70 and town groundwater contour map shows water below el.40.Bottom of overflow leaching pit is 11' below grade. / I Titles;T„ —t.;n Fnrm No.... $....211_0_0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............T-own................OF.........Barnst-a-ble----------I-----------_........................ AVVfiration for Uhipaiial Works-Tunstrurtion thrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ...R-o-a-d .... .................................................................................................. Location-Address or Lot No. ...Char .-Kin all.................................................... .................................................................................................. ................ Owner Address J .P.ma c ornb.e- ........................... ............................................................. .................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwellingx—No. of Bedrooms............4..............................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fixtures ...................................................................................................................................................... <W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid*capacity............gallons Length________________ Width__.__._--_-..--- Diameter------------_--_ Depth-____.__._._---. Disposal Trench—No_.................... Width____-..___._._______ Total Length.____.-_____._..____ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..__..__._-:.....-_ Depth below inlet_____-______________ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Per-formed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit_--_--_.-_.__.__--_. Depth to ground water_----------------------. f% Test Pit No. 2................minutes per inch Depth of Test Pit__.-.-.-_.__________ Depth to ground water----------------__-----. a ........................................................................................................................................"*...*---*---------- 0 Description of Soil...................................................................................................................................................................... x Sand & Gravel U ...........................................................................................................................................­........................................................... -------------------------------------------------------------------------------...................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ 1-1000 gallon ..........................................................................................................................................leach pit............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITI TLZ' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has jbDe issued bye board of headth./ Signed-.. ...Z ................*........ ------ra/.2-7/`8.8------- Date ........... ----------- Application Approved By............... ------------------ Date Application Disapproved for the following reasons:................................................................................................................ ................................................................................................................. . :S ....................................................................................... Date Permit No..... ..; . .. Issued....................................................... Date � «� � / ���---�-���-nn THE COMMONWEALTH ormAsaAo*ussrTs BOARD OF HEALTH Disposal ��� ��x�x»�^� � ���«��lur«o4wmu» �w`� � l Works TouWstrurtion Vrrmit Application is hereby made for u Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: '-' 5 l _ ---------------------_-_--__'--______________ 7=io"'uddres" or Lot No. ll '-'--------------------'---------'--'----'-----' ------------------'-------'--'---'---'-'---'---''-' J v°"= �u�� -'--------------------------------'----------'--- --------'----------'---------'----------------'--- 04 Instaler Address Type ofBuilding Size I-ut.-------------Sq. feet Dwel]ing=-No. of Bedrooms............4.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Sbovvcca ( ) -- Cafeteria ( ) w Other fixtures -.-----_--------..----_-...-.-_.-.-.-'----.'----------'------------ Deuign Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. Septic Tank—Liquid capacity............gallons I.coot6__'-_-' Width................ Diumcter------ Depth................ Disposal Trench--DJo. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--- ......... Diameter-:.---.-.- Depth bc1mv inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~~ Percolation Test Results Performed by. Date........................................ Test Pit No. l................oiouteeycrinch Depth of Icet Pit.................... Depth to ground vvuter------._- 44 Test Pit No. Z................minutes per inch Depth of Test Pit.................... Depth to ground water-.----.--.- _ --------------------------------------------------------------- ------ ------------------------------ ---'--_-.- 0 Description of Soil........................................................................................................................................................................ Sand & Gravel ---`----'---'-----`'--`------`---'--------'-----`--------`------'----`-------`------ :V. ----------------- -----------------------------------------------------................................................................................................................................ U Nature of Repairs� or Alterations—Aoswer when applicableT������-'— gallon leach pit Agreement: � The undersigned agrees to install the uforedescribed Individual Sewage Disposal System in accordance with | the provisions of'I ITLE 5 of the StateSanitary Code-- I6cuudcco��o�d further a�rc�a not �o place �br system in | ^ operation until a Certificate of Compliance has bee issued Application Approved' -------��- - ��' ' '-------------' -----'` ' Date Application Disapproved for the following reasons:................................................................................................................ ---`------------'-----'-`-------------------------------`--``----`------`--`-``----- ~^~ Permit THE ooMMomvvsALrH or MAssAcnusErrs BOARD OF HEALTH if own Daznntable .......... OF.---________________...................... Tntifiratr of Toutpliattrr K THIS lST0 CERTIFY, That the Individual Sewage DisposalSy stem constructed Repaired �a �bc_ J.P". � ___________________________________.____________ _______ _________ ______ ___ l5IC.�� CInstallero�___ __ � / � I �Il � � � l�_ _ _ ___ . ____._____________________________.______________ has been installed in accordance with the provisions of TZTIE 5of The State Sanitary Code as described in the application for Disposal YVocko Construction Permit No........e.c.' ...f,31.&'P..... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................�t........)J.�-_9m'.................... Iooy*otoc____________ ....................................... | THE ooMMomvvsAcr* OF wAssAc*ussrrs | BOARD OF HEALTH Tomrn I3arrlstable ...........................................OF----------------------------. FmE_$ _ZOU _ O� __ | Disposal | Permission iohereby I5l C " ==cuu^°er =' - _____.___________.___._____.___._____ to or 1 uuI � � " - Syouo e t�� j l. 1 terviI] 'i'oWN O BARNSTABL LOC�'t'iON f ( C n i S MW I GE# �[ 2 p,55ESSOlt'S MAP�i LA'i' .. aNSTn'�NA11tfI3 PIOI+B N0. SBI�I'�C IAH' '. CAPACI'[''� /Dt3z� 9 LEA iIlN04 /�—S r NNo 0VIODROONS DUUMER OR aalEgT2AT13' 1DATE�...�..- ..- Se�re�tsua esWOO Bstviee{�she; i�eei tviaxamuEm,Adjus�lGrauisiiw�t�x'L�ble�athcBattomo£ �►uc�l'�t:if��r p lva8ei tat+lr sway V 4 as�dt. obip� l?aallty .Slfoky Neils exist �,atlubet i�da ll Oilai Eii r c� let +d and L61641 . Facalicy any>w�t{ands exist Fe- wiltnloo feet�� T(C � 4 i a 17 0 _• TOWN OF BA.RNSTA.BLE SEWAGE LAGE �sta l U i'1I1�- ASSESSOR'S MAP &LOT-1 9 6 IN&T-�L 'S-NAME&PHONE N0. ; ^rlc (320A ld I?7 SEPTIC TANK CAPACITY 10G.0 !Rc� 'LEACHING FACILITY: (type) Z Y�;�S 1A Szc:t 1 (size) 9cA NO.OF BEDROOMS BUILDER ORS K,i dint PERMTTDATE: Gi 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 1 1 zu y►y� n LkLk .� TOWN OF BARNSTABLE 1 ±LOCATION _ ce_p� ,L� EWAGE VILLAGE` �,I� (/ / ��� ASSESSOR'S MAP & LOT _ INSTALLER'S NAME & PHONE NO.3• P m bey(- d SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) ct NO. OF BEDROO S, PRIVATE WELL ORCPUBLIC WATE$ W BUILDER OR OWNSl DATE PERMIT ISSUED: �.7So, _—_— DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Y, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .PV_/...............OF....... ..... ..... ...... .. . ............................. Appliration -for 4%iVaiial Works Tonstrnrtion Permit Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal Syst at., , • ation-Address or Lo Np. Owner //Ij, -Address I W /�ir �-S.CVLi_.1h�• _...J.4a'-. VY�P . �...l.Y.:..-Y9iF�✓4efr �-�i✓ --1 --- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms-.--_--_.._�---------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ____________ __ _ ' No. of persons---------(a_.._____-____-__ Showers ( ) — Cafeteria ( ) dOther fixtures •-------------- ------•--•-•--------------------------- I...........-------------- ----------•-•---------------------•----•-----_--------•--•----- W Design Flow_- -._. v.••.•-gallons per person per day. Total daily flow..............._ t ©......gallons. P4 Septic Tank—Liquid capacityl©� ailons Length................ Width-.___-..... ... Diameter_.--..--------- Depth---------------- x Disposal Trench--No. .................... Width---------------------- Total Length.................... Total leaching area.-------------------sq. ft. Seepage Pit No........ Diameter---/t_Q4 ,i>Aepth below inlet_ _______ _________ Total leaching area-._--._--.-_.___--sq. ft. Z Other Distribution box (✓) Dosing tank ( ) �t — S '� 74 , aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---••--------------••--•-------•----.... Test Pit No. 1................minutes per inch Depth of "Pest Pit_.-__-______-.____._ Depth to ground water........................ G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water._.-.--_-__--_---_--.--. 9 _-•••--------f _---•------•--------•-------•--=- O aescrpjono !20t.. Xr • i'/ --------- _ _.------ - - f.��.._ ir ,, �- - W ----------------------------------------•--- ---•-------------------•-•-----•••---•--•-•--------•------••---•----...--------------------------------------------------------------------------------- x 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 Article XI 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. Signe ............. .. � x Date Application Approved By----- -- - --- . -•---- l/ �.... . ---•-•-•- ---•-•-- C .` •F' Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ -------------------------•----------••-•--•---------------------•---•--•----•-•-••-•---•-- ............................................................................................................. Date PermitNo......................................................... Issued....................................................... Date %0 1IT10 SEW/J,C,E PERMIT 1`lO. -`� I %�.T c 14— ass t4a=J69 IMSTQLLER 5 ► &ME 6 ADDRESS BUILDER 5 Q &MF— V�, DDRF- 55 DNTE PERMIT ISSUED DATE •COMPLI &MCE ISSUED ; — — — :c 1. 'FA to A 47 1 fz YA l No............... ...... Fick . .�.''�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.. 1/ul. ... . ......... .OF........`` r.-r ...................................................-for MaVviittl Workii Cnuui#rur#ion Vrruti# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at ,-. •--••-•--- •--•--. • •--••--•-.___ .....-•---- r+ LoEa ion Address or Loj No. `.:!_/:.// _/„/__Syr.•--- -- .�./r..�i-- '-'-,�--•-/'/.A' .iC'J• ---- =t-" ...�;/J_.... �t � O�w�ner /j ddress .....G.(i.J C 'At c.Ci /._/{' ._ '/'�i ' t Installer Address UType of Building ; Size Lot............................Sq. feet Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building *-�-� s No. of persons_....... ................ Showers ( ) — Cafeteria ( ) Otherfixtures ----_;:----------------•••-------•--•------•---------- -----------------------------•----••••-•---••-•--•-•------------------• ••--______......-- W Design Flow.............' ---__`:�?.�-------gallons per person per day. Total daily flow________________ __ .....gallons. WSeptic Tank—Liquid capacitv_4_Vgallons Length________________ Width........... .... Diameter_:-------------- Depth---------------- x Disposal Trench—No- _________________-�' Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No.___-___/_-_____- Diameter_._. _ U-:-_SWepth below.inlet.................... Total leaching area.________________sq. ft. z Other Distribution box ( ✓) IT Dosing tank ( ) �� s1" 1 2- 7 ti aPercolation Test Results Performed bY--------------•----------------------------------------------------------- Date-•-•----------------------------------- 1 Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_.-_-____--__..__..__- fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water...--------------------- -------------------- xDescription of SoilK------:.�_4` -----• >-/ `" 1 -. (_�................. _ _._.._ .' ...±f4. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable..............._---------------------------------------------------------------_--------------- ----------------------------- •------------------------------------------•---•-------------••----•---------•----•----------------------------------•------------------•-----•-••--------- ----•------.. Agreement 1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI 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:---• ccr------ �°./` ��t /. ........ ........... Date, Application Approved B `�!- `?---------•=_.!".! 1/,tom- a --------------------------------- Application -- �� Disapproved for the following reasons___________________________ ________ L Date _____________•-------•••--••.._...-•----..__._------••---------_----• -•----•----------------•------------•--•--•-•---•---------------•-----•---•--------------••------------------------------•--_----- Date PermitNo......................................................... Issued..................... .................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ............ .... '(:.Fula........OF.......... ................... Tufffiratr of Tilutpliattre THIS,t IS TO C�I4TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) l (� Installer ' r ---- � �< - -- ' has been installed in accordance withliro isions of Articzl�'I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------'%__h_---- .___-_.___ dated........................"7 THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL 7 ,:/T ON SA ISFACTO Y. DATE.......... • •... ... -� ............ Inspector- •-- . .................. THE COMMONWEALTH OF MASSACH TS J BOARD OF HEALTH / 7N l l /�;3 � �.. .:.........::„. ...:. � e)F..... f�. F.- .:.�: .... ......... f...--------... -- No. FEE..-,/ ............ �t�at Trutt# Permission iz1bereby granted---- ` � ...........� '-t- ._.... ' r =--- to Const•ret ) or Rep if ( ) an Individual sewage Disposalt-t e f in 1r�t - �V v st eet— / ((,,.. as shown on the application for Disposal Works CCtruction Per' it` o._._-____ DDaated%_.�%._^_°?_v--_�_7 _.___._ _[---/--. .........I-------------------- ---- Board of Health DATE.................... ---- r FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f i tA qZ4 44 t v 4,0 cF6 ct� c3 . T S/L L. ELE✓ T 480✓E EV-4D SCALE / = _I;oAT& �` .2-6_ -2-.74, -Woe 5.. OF / 4r 4Eo?z` I �46266Y C,6Q7'1fKTi4A7 T,qc 6X 57= `p ` /N6 A0UNDA7"/ON LUCAr/QN/SCme � g'�t.�T���© � .43 S,SIOi'VN gN17�a _CONFOPiy i'Y/T/-/ OF Tf/E io K O 1 ,G .7''Un/ Z�f� /97a Doe . ®A/ ,��• t,d.�/b Sur��>'oz�. 9• Gt//GLdlt/S7:',Y.4/ZMO' TA/?�.�7'�1,Q..