HomeMy WebLinkAbout0027 CAPTAIN BELLAMY LANE - Health 27 CAPTAIN BELLAMY ROAD
Centerville
A = 230 — 176
UPC 12534
No.2 53LOR
HASTINGS,MN
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct ( V/) or Repair an Individual Sewage Disposal
System at:
Location-Addres Lot No.
Owner Address
Installer Add ess
PQ
Z Other Distribution box (/) Dosing tank ( )
Test Pit No. L.'.-2—....minutes per inch Depth of Test Pit......LZ ...... Depth to ground water...&0 H.,E='
-----''— ------------
Agrznmcut:
The undersigned agrees to install tmuforedescribed Individual Sewage Disposal System in accordance with
the provisions of T1IILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
| operation until/ u Certificate ofComo�o� 6uu6�� ��r^ ' the board of health
- R _--------- '- '---- '-- ----
_-�
Application Approved By................. cs... .-.�_�'t'��mz��xa�_-------------' ----'.��f��.cc'/�a'��-
»*=
Application Disapproved for the following reasons:................................................................................................................
.......................................................................................................................................................................................................
PermitNn ..................................
i
0.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
"rr:5(". OF.......
for Dispm al Works Tontratrtion ramit
Application is hereby made for a Permit to Construct (X or Repair ( ) an Individual Sewage Disposal
System at:
_. ....�:�:. .......... ...... ---- -------------------------------------
/Loyc-a^tiio/n-Address �f or pLotp.No y .
-'"-'"_`Y.............."�:" _..__.._........_... .. � Y:f.''._.._- '�Y-_..'`78 t_......1rw`'.'Ml ./..L:'. �`yt __.._.-.........
........... .....
Owner Address
y - ` r �
tWa 1 i�4vt Svr.4..... s !............................ f"il"T"a'=----........---------•--..........------..........................
Installer Address
Pq
Q Type of Building Size Lot... , ......Sq. feet
Dwelling—No. of Bedrooms. ........................................ Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
aOther fixtures --------------- ----------------------•-.........................
Design Flow....... .S...........................gallons per person per day. Total daily flow------ ........................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box (/) Dosing tank ( )
�'. Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. ___minutes per inch Depth of Test Pit....../.: _..___ Depth to ground water_-_�1%6a -_-__:.
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-._____•--_:•-
P+ •--••---•--•--------•--••••-----•--•-•---••-••-••-•--...-•••••••••-------•---•--•...................................................... ..................
0 Description of Soil ..r '`ar?'� '= r .. _ .----------------•-------------------------------------------•--•-----
V ........................................
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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by ithe board of health.
SignedR""= ........... .................................... __ ZZ ..........
Date
Application Approved By-•--•......•-•� == �� � '� :� ...•--••
Date
Application Disapproved for,the following reasons:..............................................................................................................
.....................•-----.......----------------'-------------------------•--------------•--------......---•-•--------•--------------------------------------------------------------------•-•••-•-•---
Date
Permit No............r�.....; .-. .. :.. �.............. Issued-.......................................................
'.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................OF... `:.:. !, .........................................
wrtifiratr of TomptiFatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed V" 1 or Repaired ( )
by ---.: .:�� f.
Installer l l r
has been installed in accordance with the provisions of TITLr, 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......;__.:z_- C,r... ........... dated--------7"__'~ "__�_____.________._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION ATI•SFACTORY.
DATE-----...-- —i ...3.t. S-•-- ----------------------- Inspector........ ... --------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'" ""_
No � FEE -:��:. ...
Disposal Workii ~Tol�onitrudioat pautit
Permission is hereby granted..........4NN' ...... l t . ------•-----••-•---•..........................••--........
to Construct (A or,Repair ( ) an Individual Sewage Disposal System
at No.....j ' -It_5......--•• " � fi
. •---
........
Street
as shown on the application for Disposal Works Construction Permit No.4:,=`___f ?_:: Dated_._. �� ---------------
i
.. .� y _1
Board of Health
DATE.............••• •• •.-•-••g-5----•---------.........-•-------........
FORM 1255 A. M. SULKIN, INC., BOSTON
r f1
or -L I f"
lli t r 1 a 1 ; f ", J E jt" "":.3S.4,t.j [ F ti y >, k, fF, b.-�y ,. t Y x,- f ' S" ` t y ''F i - 4 r Y , c1.
�1.,',,�,,1',A!,.-,II.1l.'�,l`iI,�i-It�I��.,i"Ivj,,;,��..;._"�--l-;,,I,,.,r.-.i"-4'.".�".'l",,1,,,,k.��:-,�,",tI,""—�_
"!l 4 J14r y tF f t t r t " 1 .4 r,1 k 1, r t t ."
1-4
1,4
.1
3 ',% 4„ I a -ti S t r ,; _.<zA x x -S r l xe t�i<;,' ri ti t-:_ a, " :3 ( T
A,!" ,'I a irz b [ s t i [ i. > tR .-t a- a �t rz �• y, t n ,.s e
1 k{ t x
IrN ��, ,f rF - # t t h^ 4 rtFt_ r ,v 3 :` 43 t ptit ;f ate- i , '•
' 4 4l,t,4 ..I d r a ��' 'Y �} 1 +, P t ,:f : h r 4 y. �.� '';, < *dK '�:
V,{ ,l"G Lv S d';vj A rt « s t £ r t st s e t.e. x x '€ -t }st fi.
_ l a f d 7 `
, x d, ,tvt t r �i `i t o- a. i, ? 1 < t o-.(�
f,gzZ r LF-i t I i S s ^ ti r R i - *L J ti
s-
�'i� 8y,{/'t``Iy z. ..k t i'' �} �t t T _ S C'd , k, 1 Pk
t{ iw y # .k r. 1, - qA :cal *$k5 `F r' F. i' r t s ,r t*! 5 6
S kC`, syq �'y `4x� ' y Ctx [x y s: .rI- t s n S ,�� y, ,� x
r t t# v :"
S 'cam.?' ry `y`$ �'z f 7` y t 31 j«"k y r a k t + S a t ?"? :ka y
Kyrj 8T Y a,��J''i3 ;' ! Y *t t-r Ss >t s:y,� - a "-- '1 ti I`>;,t a D .\ h { '� �'�
,+< �y*.v`l a� ti.y 1 .-t! .t -;� :,,i, ,;`��d p `rr�mr �`t-t y'r �'sx 4, z ``v Y s .: ,
'eet)_—
`.Fi-;3..-I 9 ,f�.; d, * S. J y '0 /h..t-� xr �y �. j
r I, I i4 1 i y 'T, ^k. ,E
7t^ e mu f t { K I p Z�1 y��r }` / 3
yam, „'^^Y } SF�.ti 3 q ,. 4� y+fH{ fz ai'r7l t�'�? �t ,` S /''•���/jn? r _,w ` i. +r'«
2Nb7 "ti, ,?,�`� J yam. / i Ya t 2 f . Nr\/'4l �? ` , \\\ `I ,7 >K,,
Lf tia y't5•Gy&.Sfi %t 'rk zi i t` # t'''w .RYA yet�+r:tSa.s{`1}'.,C.'i't+� G. _r -/t. y �` 1Y 3x,:
t r igr ;d.S r3i ;�" 't f 4:. 1 [ n ,e..7.p s, ti t 5d�tt..{a 51�i ' �� �`V- / �' V A�t f: t
x • s ^ti t 'A,„ ,k't 4 t r ',�D �, ay 3° s! I 3 x',t. ` ) -S
+ , , tyr a '.6 '.. .#� j .. t r``.. v �/'' iy t}klF S t 'tT`` R/. ga^'}' 't �j y 3 ,� "
487')r t t s ', ���qq I�}n y.�+ ai �,,,, L ;i g u. I { •:
ft, T ,v r+'t 7 ;.', £ `z ,• .r FV V !„ s,� t �,,; - 3' 4 r /] ., 1 i ` •r
qt fqs }�^ f _ .l s e p FB,Y .tF1trQ� st a rt `�Yi Sze, x !!! i+ a
ti fit', � i' _ V fi f,Ah 1 R sh Y a' s i Y_i r' t7 lid -�- a,�% ,« 's. '.ems ',1 �" :'` a'u i \ s.,t y
'',y'. iI._ 't 4 t r -1 Y ri�l- {+t r� �r- 2 5 F Y, t$ .n `� f l'v / SS
3 � . . °I' '�"t h* •r �S'r r.� n M1 1 /.-0 f i ��:s•. x h'�1 3, (, - _{' 4
-t '` i r{fi t ;} lk t r •�... �Ir ' ly? S�e�� 'r II 1,7t r _,PT�tF f:. ' * �� t�- I f :- r� _ �' }' t fa
r.S"2'k t .r k S a i f... k. t. r 20 77 a a L f r
$ '`"'�^ tt'°"ra"' wf It t a 1 r� .1✓a -, :�i .. r.'t �i a 7�• • :.M �t7 4 a
c +, x s 'V
• ,•• °♦n r r 'Y` a.;:i s�°s 'Yr. c I� x-, 'r' '_:.. t' e
4'"i 1./t�`�t-y}}+' i$?�r C �. ' +kyr ° k / tit ."r"' P, r `
,,tS Y"F"��tt^+' 4 ' .0 - s } f O } Yry t y t '/ V ,y.r
Frti, rzrltpl�11 c ^-. �q''. �a,x rr# f r # 'pl 't s 1 \ �4':n r 1
xoi 1 .�yt#x ri e yt ix T Fy;' iy ,_.(, s F)s k-ram 3.�, � �--- , 1 \ ', t.:
ltyxa f X 5',z,•, �.Yyti ;f\7 S i /�' d'„'i ax r. 1, S L}tt11.. y ' Ott, ,((/�
1I"r1�,...,1..,",.:.1,I�,1.,I�.�.�I,5/_.����1...���,.*���..".
x � 'I� ` ,{i..t i "r t, r.tY t r2 "+,_ e` i/3 a [ ; . 4 v J. ':
jai Sye , ,c ac r < r 4 , 'may, tx v `s e ,� - °-
?w { p�J; �i ` j 4 t ck' �Q Qp t' 4 } 1 . ..
' t,, 7,«1 z rS °' t, { �• `,�j , ''Rv�- o z+1'r'j2 t� t vr�a: ` j
lo-r .r y hx rr K yr"tyft,.�' '; r >l r "�;: rt, i�I 7r"'° lk, tt;�� , .I w ,N>.a / ./S.. t t .
��,x ^,
Fsc 3 i tr �zr,t'f, t .Yea t, _ r v' 4.y y 4 }:
f ' tlY s fy" 4'tt z t �! 3f W 1. /� i _ a
i '4i S �.-, w .I[ >. r F�� � ,y b s x� �.'- �, l `.� t 1 -1Y+,,'6.
f r. i.,A r`•if"I r`"ti Tza , b t'l �.i•'� ,c. , E � t)s'wRd s ,�,,L i .* `. ,J e{w Y x x:... ^ .. -t
s.e a ? r �` S " [ S 9 a "r,%� Y o:. ` t'' i ?.h' t 5 Caat a is a o-f 11a Y L .. y r } ay
NY fi A "' .ef y ;J �; Y... 7f� l z'fi F S S
y+;R}' ,il1't teak � , / t 3 .3 S S ",-, D�4/"1� �— Y t_+ ,
iP t y YO£I dry r n a xf[ . t. I(L.y is o t ' t
' �A;tT'�rFe-
7 }d4.$J 1 r x n[ t., .. t t}'{ t.t {z �t t^ [- h
Sr t r 4 r t t tt J i .5 x }v A°
r iz� +}4v. r y!,... \ �1N. //11- a t -a r .; "at'i, xi �'' r ..,3.5,.
t ,' ; LCF3 Qua .s1 I r A. ;
^}s� NO 15367 � i r° r t ,, OF Agq�
a ' 1 �4 C,r " s( e � f t �c4P S9� r
! VA i,�z°t rs, t�ISTE� t� c{t s
ar xkss .h i V/Q� _5 'a p.' ty; t gLBERT G' - - y
3 wk �� "A J ���;. � f.A fi t�: a rn{ Cz - t
rtl F�"[�' ND ., a 3 .1, y MORSE v,
4..
,1
ji. �, 18TIN®�'SPOT ,ELEVATION 4 OxO:
+ + No 10951 O • -
A�.,F�i$ �`w CERTIFIED Pt_OT PLAN'' t`
"EXISTING `CONTOUR r---:0 _.�. ',. '..
"'`` yfiMl> HRDs..9P0T ELEVI�TION 'll7 s`�O1Ja��`'� GD7' S ,C'ffT�7; GL�9�'�1 LAN .'
li� l4tllQ CIJNTQUR t-�---0 ---�--, A se J��T }� �^{L 17 u }n.f 7 t t. s n 4. o- ^" , b ,."a t%'t4,c r.�hY ' '.ly� ! X. ��.y T � -/_(_. L
�r iQTE;: The '1{oc.at ion Iof, any.:exis G'ing under ound:sewerage, T.
.4.! ..i.�;....... 1 N a
"fix r ils; or 'other""µtilit�e$ shown;on trI plan 1. approx
4 M - d 4. C
1M Y { •$ t >
!* }ma,�iR i y`as claterm ned €rpm �cor saand/ax verbal 3 x ��1 `�
�J tprma ion,k The contractor�is�xespot�� hlei�for` the�'',, �A wS JrA.0L.94', �AI,�
i'vorMMt cat on of`:ttW xi.st ng locet_ipn$A$in the: ieid' , ` 11� . /���3" `
SCALE / 90 DATE
� ' �pIQ,EDGE: NG/NEER/M�'�cct hV r - M lg .
- k CLIENT. I -.CERTIFY' THAT THE"PROPOSEp u
` f41$TEIifE, t �E01sTERRQ `� JOnNQ;ecl3 ��-- ,BWIDINO• SHOWN ON TNIS :PLAIN °.
� y,.
i�1 kktt,3 e. 3 v r ,, » r
�,r C1-, � }`LAND';, D� �Y CONFORMS +TO THE ZONING AIIVS x
'y. ER r m - - -- OF `9AR.NSTABLE - MA'Sc , !
,�r k k F a 4
Ar F w k r T 12 M A I.N 8 TR E E'� ;i,;��� t CN, ay- .6. /8 �s -.
X
�, t ;, SHEET Of` DATE REG. °L'AN0 SURVEYOR
.
't__'�'wa,,.�..a.�r. -..s_t..tyJt��_.. .. ,r,: ., r. -. '�.+„.Y= y 7 ..�,t'.'... .... r.5°�_ s.s- ,+s
.r-
., .+a -
.. ., ..-. .,... � .. .-_... 5;., <.-, s ,`y3-.r..s. x.,•r_'t. ,.r-1,.. >. i._g i. .... ..i.,,, ',.... �_�,e- ,.�„�',:s •� h-• �. ..a_. ew„ti:- .;rra_ e�.. .� :2 ..,.w v��.`iY'. _ .>..., ..r.�-.,a. y, ,•-..,,,.�.. ... c....-.':_s .k...-.. vs,-.r_, . ,,... k.x3`::: s.4.r
xz. •�.�.. «:pis•, s. .:a. a�x. -..y.�f 1. h- i.`'.:. ,y*,. 4y sr, ,-w,•9' $t �,:a� *� +,;s ti- �'` cr .,I'- ..k:
i„�.• i. 7+F' :t.t, z .. -,.. T 1-' # ri'. t. ..y: � e�:.�..
.,.� p ;....�':LW •, a.zz -.. .. r.., 1 �7' ... _.
p S
'$ .} .y. ,,+. 7R .y �:'. • L'.../Y,.y... �.;.�.5 't, �: � �` •'+. '}-^l5.75� t ...T-. .... ..":......:.. .'f .,g.?...,
--.ia -,x• •\.yt'"h:
,,. .; ,;: ,. �.fi TN /G TANK: OR
,.Y.- - « .-t > •+e. y fi. :.+t. h .. ., s ✓ ST r "` 'n; r E'•SEP
...s. y.: • � ,Z3• 't. ..,`fs.;, a ,;*�- ..- :a .v�'.��E.w. r JF
.. o �c�;r .vG-x�,/r >yo:�E .ram+ .IZ e�
LE t
777
2st'O%AMET.ER
r 0 7 5t/i9L[ ;BF 4•4O41G%NT. Td GI?A'OE:W�%4N Eit'TRi4
_.r„ 3,re q'OYL' PIPE z 1 3/ steyR07Y CCYER SHALL BE LiSE.O
CON jylN-'.l�/TCN `!
CLxS D Gov 8'lvFR FT OR/VElt!.4 r
•4
• GR'TE
�- i 1, ! c c ✓ER
b .DOE CL EAN• SANG
�w 2�LAYER
S 1�C. PIPE l0 l9 D � _ •,. QF.:
ff : .MIN.orrc/v GAL. 1 , ` • ', :• • e WA SNFD STD.' 4E
SEPTIC 'Ti4NK •
DJST o
f2
• + � 8 • .� • • + .�• _'
7r 'i ►` 1 1 �EFFECT/✓E + • ,, 3l4
i r : •. .. . • 1' DEPTJ+/ • 1 • 0 WASXEJ S.74. E.
-
�. J-7 •`�� 1 �. • • • • •• 1 O p'• /-lQEG9S7-:SEr/E
u •• �a 4z ° , !� J 3 •= ti -.I D• 1 • I ♦ • • 1 • 1 •
,� XNi�iE'SST^CLEyATlDNSP/T +sP.�cery 4Jo Es+ Y, -
a , 4
lNYE/tT AT QU/LD/NG 0 FT. <-3 J-z`, G/�41rJ CCF7p81/t.aTlON�
%NLET SE'PT/G' �-
Otl7LET.SEPT/CTANK9.3 FT
!/VlFT DlSTR/BIIT/ON eOX, F7,. GROUND h�i4Tf/� T/�DLE
8
SECT/ON CF
7dTLETD/3TR/Btl7"/OIV 6Q1�' o FT .esLcW/4CsE• ��s��S'Iq L�'�'Y.STiE/�'! -�� T!'; r
IKL.EF LEACHING I�/T 48:.• �T r., < T/�4WZ-A DN' ;'
LEACH//V6 P1 T DiMfN.SiON I� -FT i
t GN tt/TER/� sc�LE'
i DES/ 'C l+(i l�
. E�00%fS 3 D MtJti/S
GAROAGED/SPOS/!i UiY/r SOIL 'LDG SOIL TEST
TOTALEST/!►L�TED FLOW .:33`U G—AL./D.ay. SOIL TEST ,IEI .. .SOILTEST/E2
NUMBER Gr LtAGMlNS PITS ELEY. ELFY. DATE OF So/L:.TEST
S/per LEi4CHlNG PEft.R/T 151 Siv, F7. r _Z l �. RESULTS ls/ITNESSED dY 1�/1 w�G
1/3 U. ss INCK
DoTTOM 1b'1CN/NG PER P/T $Q. FT- LC�p'4,f PERCOLAT/ON �4TE
TOT1lZ LgACN/iYG« •4RE�4 ' ZG 4 3Q F7 rs/3.S v/t-. )CWXCOLAT/ON.RA7AFMIIv
�ESERYELEAC.H1N6 AREAFT. r r
'2 v
23
ALBERT
a7/ A. • rii r.
a$J �AORSE r ! v ;a€ � x
. No.33951 O , No. i�367 ��� �11�.
I9G I
�7 S '�1 9., MA
5. 4 L I R CLIA '�
f �/ / ! P yY4TER EJVCOUNTEKEQREEAI /fir
,
GRoulvv yvs�TER ,�r Etcr� J4B No 8309 / �1L�JFT z-o�'
-L,::,y `'''i-Y:k'- �- r s - i^ _ ny.k t x, »` S t ;.iw• �� 4' t t- ': �.a*y,� ..R a'S. F w• 'x x`. rxY'ai /w ,
: A:::r t i.. .;.x;.11..^ :.:<aa..'. M1..•.l-;R.n_ 5.':..' .:i.,.' . . "� i i. 1 n,3..::...-.,-�,,.ef -.s_:1.;,.;..s. ..L:::, v.M- i�.,2.:Y::'.. �+5s::k.:,.=:�-;N:1F�t^."1v?'9�:4-.F-"K',ia`^6�^-YnS:..:"i...G.+"`.::'4"?".`.S^9t.t.✓ IASM.fr',...4 e:[.�
TOWN OF BARNSTABLE
9 r -
LOCATION oZ �' �G I�. �.� SEWAGE # --3
VILLAGE ASSESSOR'S MAP &LOT Q /
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I o
LEACHING FACILITY: (type) (size) 2
NO.OF BEDROOMS
BUILDER OR OWNER X.26 oc—
PERMITDATE: 7/ / /9 S' COMPLIANCE DATE: 7/3 43 S
T
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
I� I
r �
` 5r '9h '
rLa'eAATION q �� SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME ADDRESS
wtA,C 54c) s AM : 5
e U I L D E R OR OWNER
l �,J
DA. T'E PERMIT ISSUED
DATE COMPLIANCE ISSUED 3i -
� -
�-
Y ��
� a
�L� Z>
��+� �. �
scow�
1 �
t
TROY WILLIAMS (COPY
v
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 760-1819
40 Old Bass River Road
South Dennis,MA 02660
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
0AX7°4lJ "EC u.gM/
Address of property o2 7 C N-/- f 1c, �y �ti C_�h
Owner's name& A,. U r,,) /t/l.-s ��.,�� I 1 Doy/� 1� 1I l2
Mailing address _5"" ` 1
ch Date of Inspection 9 RUM/moo �y 5
PART A S EP 2 7 1995
CHECKLIST °D
cc
Check if the following have been done:
A �
Pfe,�, Pumping information was requested of the owner, occupant and Board off
1 ,-5 None of the system components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large volumes of
water have not been introduced into the system recently or as part of this
inspection.
YE s As built plans have been obtained and examined. Note if they are not available with
N/A.
YE 5 The facility or dwelling was inspected for signs of sewage back-up.
YE s The site was inspected for signs of breakout.
Yes All system components, excluding the SAS, have been located on the site.
Yt s The septic tank manholes were uncovered, opened, and the interior of the septic
tank was inspected for condition of baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge, depth of scum.
L s The size and location of the SAS on the site has been determined based on existing
information or approximated by non-intrusive methods.
YE 5 The facility owner(and occupants, if different from owner)were provided with
information on the proper maintenance of SSDS.
Page 1 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
_j- _number of bedrooms
_number of current residents
No garbage grinder, yes or no
YE 5 laundry connected to system, yes or no
/,/o seasonal use,yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
�3 = 701 00')
JL• Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
/ s 4- e- v,, —I a /5 /Ys y/a3Aa t2-ey ; h� o �, t' a
>u tio&,&,e- cLAJ1. «
HO System pumped as part of inspection,yes or no
If yes,volume pumped
Reason for pumping:
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (If yes, attach previous inspection records, if any)
Other(explain)
Approximate age of all components. Date installed, if known. Source of information:
ffed -7/��
NO Sewage odors detected when arriving at the site, yes or no
Page 2 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: V (locate on site plan)
depth below grade:
material of construction: concrete metal FRP other(explain)
dimensions: 5 X
sludge depth
/y 1• distance from top of sludge to bottom of outlet tee or baffle
NoNr 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
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation
to outlet invert,structural integrity,evidence of leakage,recommendations for repairs,etc.) ' I 1
i0y c- / L Ar--II i k �,t/.'! G. -C) L O�. C-,V` 7-c -�+� t_- 7�v G./7-�t T
Jh-A •. r.. rg u U WJ ✓' ;k IVU i 9 c S O 7' le-o.
Q✓ 1 S�✓✓L�/r rJ G N c. O G k G.JK 1-0 -1114/' / 4
A Lc "L"AO N a Z). 4- (.e 4 % ✓J-� Was /�c h !y
6Ut- fvo.S r+U f Ob5L✓vc� oy C-uJS, ��
DISTRIBUTION BOX: vX (locate on site plan)
l W� e,/. depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,
recommendation for repairs,etc)
, W v c �. h i r.�o✓k% ..�
PUMP CHAMBER: /�//A (locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, recommendations for
maintenance or repairs,etc.)
Page 3 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
vegetation,rec
ommendations for maintenance or repairs,etc.)
5� ,O 7'c Imo.-, �Jb i s�N i�rG�� cr � � A, s
u✓ o v „9.ry �,(.c •� 3 / L, 7 L, < /✓�S 7L.
CESSPOOLS (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
(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of
vegetation,recommendations for maintenance or repairs,etc.)
PRIVY: ^1114 (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,recommendations for maintenance or repairs,etc.)
Page 4 of 7
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
a6i �
3.Jel;
i
3� y,
DEPTH TO GROUNDWATER
5<< 4`law depth to groundwater adjusted high groundwater Ievel
method of determination or approximation:
fL-h d f}✓ .ay L `7 / S L /o/ ,., b.� �y�✓L /c o�c. I tt 9
iao
Page 5 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes,no or not determined(Y,N, or ND). Describe basis of determination in all
instances. If"not determined", explain why not)
I/ Backup of sewage into facility?
A�Discharge or ponding of effluent to the surface of the ground or surface waters?
/V Static liquid level in the distribution box above outlet invert?
/,/,/l Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow?
Required pumping 4 times or more in the last year?
Number of times pumped
/U Septic tank is metal? cracked? structurally unsound? substantial infiltration?
substantial exfiltration?tank failure imminent?
Is any portion of the SAS, cesspool or privy:
/u below the high groundwater elevation?
/\( within 50 feet of a surface water?
/14 within 100 feet of a surface water supply or tributary to a surface water supply?
—jV within a Zone I of a public well?
N within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies
only, not the SAS)?
/y within 50 feet of a private water supply well?
less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis? If the well has been analyzed to be acceptable,
attach copy of well water analysis for coliform bacteria,volatile organic
compounds, ammonia nitrogen and nitrate nitrogen.
Page 6 of 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: Troy Williams
Company Name: TROY WILLIAMS SEPTIC INSPECTIONS
Company Address: 40 Old Bass River Road, South Dennis, MA 02660
Certification Statement
I certify that I have personally inspected the sewage disposal system at this address and
that the information reported is true, accurate and complete as of the time of inspection.
the inspection was performed and any recommendations regarding upgrade,maintenance
and repair are consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check one:
�I have,not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303. Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and the environment
as defined in 310 CMR 15.303. The basis for this determination is provided in the
FAILURE CRITERIA section of this form.
Inspector's Signature
Date 71,-,2 O 1 S�
Original to system owner
Copies to :
Buyer(if applicable)
Approving authority� rK 5 6 lc 3b-(�/�
PROPERTY ADDRESS:
Page 7 of 7
LOCA.T.:ION a SEWAGE PERMIT NQ•
97
VILLAGE
INST.:A;LLER'S NAME i ADDRESS
d U I l< #:E R OR OWNER
DATE PERMIT ISSUED
D'AT .E c` COMPLIANCE ISSUED_ 3i
M
Zj�
scow�